J 


BODILY  DEFORMITIES. 


/ 


BODILY  DEFORMITIES 


AND   THEIR 


TREATMENT 


A   HANDBOOK 


PRACTICAL    ORTHOPEDICS 


BY 

/ 

HENRY   ALBERT   REEVES,    F.R.C.S.E. 

SURGEON   TO   THE   ROYAL   ORTHOPAEDIC   HOSPITAL,    TO   THE/EAST    LONDON   CHILDREN'S 

HOSPITAL,    AND    TO    THE    HOSPITAL    FOR   WOMEN  ;    SENiC>R   ASSISTANT    SURGEON 

AND   TEACHER   OF   PRACTICAL   SURGERY   AT   TH^   LONDON    HOSPITAL 


WITH  228  ILLUSTRATIONS 


PHILADELPHIA     . 
P.    BLAKISTON,   SON   AND   CO. 

1012  WALNUT   STREET 
1885 

(All  rights  reserved!) 


-RJ)73 

Iffs- 


2,7 'Ztt^ 


PREFACE. 


This  work  is  the  first  of  a  series  which  was  projected 
some  time  since,  and  is,  I  believe,  the  original  instance 
of  a  collection  of  monographs  on  the  various  departments 
of  Surgery,  Medicine,  and  Gynecology  of  a  comprehensive 
and  concise  character,  at  a  reasonable  price,  intended  for 
publication  in  this  country.  That  the  idea  is  a  good  one 
is  evidenced  by  the  announcement  of  a  similar  series  some 
time  after  the  present  one  was  arranged. 

With  the  exception  of  works  on  some  of  the  sections 
of  Orthopedic  Surgery  by  well-known  Orthopaedic  veterans, 
no  book  of  an  authoritative  character,  i.e.,  founded  on  a 
large,  special  and  general  experience,  has,  for  many  years, 
appeared  in  Great  Britain.  Indeed,  so  far  as  I  know,  there 
is  no  work  in  any  language  dealing  with  orthopaedics  in  its 
modern  sense.  This  gap  I  have  endeavoured  to  fill,  and 
though  no  one  can,  or  should  be,  more  conscious  of  the 
difficulty  of  doing  justice  to  a  rapidly-growing  surgical 
specialty  than  the  author,  yet— if  he  like  his  subject— his 
labour  becomes  lightened  by  the  reflection  that  honest 
work,   however    imperfect,   will    meet   with    its    meed   of 

appreciation  in  candid  minds. 

b 


VI  PREFACE. 

It  will  be  observed  that  I  have  omitted  any  detailed 
account  of  joint  diseases  and  other  subjects,  such  as  hare- 
lip, cleft-palate,  and  plastic  surgery  generally,  which,  though 
properly  included  by  some  writers  as  orthopaedic  subjects, 
are  large  enough  to  claim  a  volume  to  themselves  in  this 
series. 

The  general  results  of  my  experience  at  the  Royal 
Orthopaedic  Hospital  for  many  years  have  been  included 
in  these  pages,  and  I  am  preparing  a  statistical  account 
for  separate  publication. 

Some  subjects  quite  new  to  British  Surgery  will  be  found 
in  this  book,  and  I  would  refer  to  the  chapters  on  Spring 
Finger  and  Paralytic  Dislocations  as  corroborative  of  this 
statement.  I  have  also  endeavoured  to  do  justice  to  the 
pathology  of  my  subject.  A  new  and  successful  operation 
for  nasal  depression,  with  suggestions  for  another  on  the 
nasal  bones,  are  noteworthy  points.  I  have  found  it  neces- 
sary to  adopt  a  more  correct  and  natural  nomenclature  and 
classification  of  club-feet  than  is  in  vogue,  and  such  a  pro- 
ceeding should  need  no  further  explanation. 

The  illustrations,  with  the  exception  of  those  represent- 
ing instruments,  have  been  taken  from  my  cases  or  photo- 
graphs, and  it  would  have  been  easy  to  have  increased  their 
number,  but  I  preferred  to  select  typical  or  remarkable 
cases.  Most  of  them  were  drawn  by  Mr.  D'Alton  ;  some 
by  students  at  the  London  Hospital,  and  a  few  by  Mr.  E. 
N.  Smith.  I  beg  to  thank  these  gentlemen  for  their 
accuracy. 

I  am  indebted  to  Mr.  Schramm  for  the  use  of  a  large 


PREFACE.  Vll 

number  of  blocks  of  instruments,  and  to  Messrs.  Mayer 
and  Meltzer  for  the  blocks  of  tenotomes  and  the 
osteotome. 

The  work  has  been  written  from  the  standpoint  of  a 
general  surgeon  interested  in  a  special  domain  of  surgery, 
and  I  trust  I  have  shown  that  success  in  the  treatment  of 
orthopaedic  cases  depends  very  largely  on  extensive  experi- 
ence, personal  supervision,  and  watchful  care. 

Though  I  have  found  it  necessary  to  differ,  here  and 
there,  from  the  views  of  other  workers,  I  hope  I  have 
done  so  with  the  recollection  that  we  have  the  common 
object  of  doing  our  best  to  advance  the  science  and 
practice  of  an  important  domain  of  surgical  work. 


78,  Grosvenor  Street,  W. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/bodilydeformitieOOreev 


CONTENTS. 


-o — 


PART    I. 
INTRODUCTORY   OBSERVATIONS. 


CHAPTER   I. 

PAGE 

Orthopaedic  Surgery I 


CHAPTER   II. 
Rickets  Surgically  Considered 10 


PART    II. 
DEFORMITIES   OF   THE   SPINE   AND   TRUNK. 

CHAPTER   III. 
Spinal  Anatomy  and  Measurement .21 

CHAPTER   IV. 
Curvatures  of  the  Spine 30 

CHAPTER   V. 
Deformities  of  the  Thorax 78 


X 


CONTENTS. 


CHAPTER  VI. 

Deformities  of  the  Abdomen 


PAGE 

80 


CHAPTER  VII. 

Torticollis  or  Wry-Neck    ........       83 


CHAPTER   VIII. 


Cyphosis  . 


106 


CHAPTER    IX. 


Lordosis    . 


118 


CHAPTER   X. 

Vertebral  or  Spinal  Caries,  or  Spondylitis  . 


124 


PART   III. 
DEFORMITIES    OF   THE   LOWER   LIMB. 


CHAPTER  XL 

Talipes  or  Club-Foot 

Pes  Equino- Varus 

Congenital     ,, 

Acquired        ,, 

Paralytic         ,, 

Untreated  and  relapsed  Varus 

Pes  Varus 


CHAPTER  XII. 

Pes  Equino-Valgus 

Congenital  Equino-Valgus  and  Valgus 
Pes  Valgus  Acquisitus        .... 

Valgus  Ankle 

Congenital  Valgus     . 


146 
152 
153 
159 
160 
16S 
177 


181 
182 
184 
196 
197 


CONTENTS.  XI 

CHAPTER   XIII. 

PAGE 

Pes  Equinus 205 

CHAPTER  XIV. 
Talipes  Calcaneus 218 

CHAPTER  XV. 
Pes  Cavus,  or  Plantaris  ;  and  Pes  Planus 225 

CHAPTER   XVI. 
Genu  Valgum  and  Osteotomy     .......     232 

CHAPTER  XVII. 
Genu  Varum  and  Curved  Tibiae  ......     284 

CHAPTER  XVIII. 

Congenital  Misplacements  and  Deficiencies  of  the  Lower  Limb  .     292 

CHAPTER  XIX. 
Deformities  of  the  Toes     .         .         .         .         .         .         .         •     311 


PART    IV. 
DEFORMITIES    OF   THE   UPPER    LIMB. 


CHAPTER  XX. 

Club-Hand ■    .         .         .         .326 

CHAPTER  XXI. 
Deformities  of  the  Fingers         ....•••     33^ 


Xll  CONTENTS. 

CHAPTER  XXII. 

.  PAGE 

Contraction  of  the  Palmar  Fascia       ....  .     353 

CHAPTER  XXIII. 
Jerk,  Snap,  or  Spring  Finger 373 


PART   V. 
ANCHYLOSIS   AND   OTHER   DEFORMITIES. 


CHAPTER  XXIV. 
Anchylosis  and  Unreduced  Dislocations      .....     383 


CHAPTER  XXV. 

Nervous  Deformities  and  Muscular  Contractions 
Infantile  Spinal  Paralysis  ..... 
Paralytic  Deformities  of  Upper  Limb 

,,         Displacements,  &c,  of  Lower  Limb    . 
Muscular  Contractions 


421 
422 
426 
430 
432 


CHAPTER  XXVI. 
Deformities  of  the  Nose  and  Ear 437 

CHAPTER  XXVII. 
Contractions  and  Depressed  Cicatrices 443 


APPENDIX. 


Osteotomy  for  Irremediable  Equinus ...  .  447 

Trephining  in  Pott's  Disease       ....  .  447 

Absence  and  Deficiency  of  Clavicles .         .  .  448 

Dupuytren's  Contraction    ....  ...  448 


Index .        .        .        .     45I 


BODILY   DEFORMITIES 


:o: — 


PART    I. 
INTRODUCTORY    OBSERVATIONS. 


CHAPTER  I. 


Definition.— Orthopedics,  or  Orthopedic  Surgery,  is  that 
branch  of  practical  surgery  which  deals  with  the  correction 
of  bodily  deformities,  from  whatever  cause  arising.  The 
term  orthopedic  is  derived  from  two  Greek  words  signifying, 
to  educate  or  put  straight,  and  the  term  orthomorphic  has 
also  been  used  to  signify  this  branch  of  our  art  which  puts 
parts  into  their  straight  or  correct  form. 

Scope.— In  its  widest  sense  orthopaedic  surgery  includes 
the  treatment  of  all  deformities  to  which  the  human  frame 
is  liable,  but  custom,  and  the  practice  of  special  institutions, 
has  limited  the  grasp  of  the  subject  to  the  treatment  of 
the  various  maladies  discussed  within  these  pages.  Some 
authors,  however,  have  included  in  it  many  branches  of 
general  and  plastic  surgery,  such  as  the  correction  of  squint, 
hare-lip,  spina  bifida,  imperfect  rectum,  cleft  palate,  &c. ; 
and  though  these  undoubtedly  are  deformities,  it  seems  to 
me  that  the  subject,  as  generally  understood  in  this  country, 

B 


2  BODILY   DEFORMITIES.    • 

is  large  enough  in  itself  without  unnecessarily  encroaching 
on  other  surgical  domains  ;  so  that  I  shall  confine  myself 
chiefly  to  the  consideration  of  the  pathology,  diagnosis, 
and  treatment  of  the  deformities  of  the  spine,  and  of  the 
lower  and  upper  limbs.  The  branches  of  surgery  just  alluded 
to  will  be  treated  in  other' volumes  of  this  series. 

It  seems  scarcely  necessary  to  define  the  term  deformity, 
but  it  is  well  to  say  that,  as  a  general  term,  it  includes  all 
deviations  from  the  natural  form  of  the  bodily  parts, 
whether  congenital,  or  acquired  by  disease,  accident,  or 
surgical  traumatism. 

Those  interested  in  the  history  of  orthopaedics  will  find 
valuable  information  in  the  "  Histories  of  Medicines  and 
Surgery  "  of  Hseser,  Daremberg,  Rochard,  and  others,  and 
also  in  various  orthopaedic  works ;  such  as  those  of  Bauer, 
Sayre,  St.  Germain,  &c,  but  it  is  beyond  the  scope  of  this 
practical  series  to  give  even  a  sketch  of  this  interesting 
subject. 

General  Remarks  on  the  Causes  of  Deformities.— 
The  conditions  producing  or  favouring  deformities  are 
various,  but  may  be  classified  into  congenital  and  acquired. 
Of  the  former  the  varieties  of  club-foot  are  examples,  as 
also  are  congenital  rickets,  intra-uterine  fracture,  etc.  These 
congenital  cases  may  be  divided  into  mechanical  and 
nervous.  The  mechanical  view,  i.e.,  the  causation  of  club- 
foot and  hand,  etc.,  by  position  in  utero  is  again  gaining 
favour,  as  against  the  view  that  these  conditions  are  due  to 
contraction,  spasm,  or  paralysis  from  disease  of  the  nervous 
centres  or  nerves.  Excess  or  defect  of  development  is 
also  a  frequent  cause  of  malformation,  as  instanced  in 
supernumerary  or  deficient  digits,  hare-lip,  cleft-palate,  etc. 
Other  familiar  instances  of  defect  are  spina  bifida,  intra- 
uterine amputations,  and  cleft-palate  or  bladder.  Partial 
absence  or  defect  of  some  part  of  the  body,  as  of  the 


INTRODUCTORY    OBSERVATIONS.  3 

limbs,  also  occurs,  and  certain  defective,  or  otherwise 
abnormal  conditions  of  the  joints,  are  known  under  the 
name  of  conge?iital  mis-placements.  Mr.  Roger  Williams 
has  recently  shown  at  the  Pathological  Society  a  case  in 
which  the  femora  were  absent,  and  Mr.  John  Wood  has 
also  recorded  another  instance.  This,  like  most  similar 
deformities,  is  irremediable.  Intra-uterine  amputations  due 
to  strangulation  of  the  limb  by  the  umbilical  cord  also 
occur,  but  are  of  course  only  to  be  treated  by  artificial 
limbs  when  the  patient  is  old  enough. 

Among  the  acquired  causes  are  injuries,  such  as  fractures, 
dislocations,  diseases  of  joints — whether  traumatic,  gouty, 
syphilitic,  or  rheumatic — rickets,  osteo-malacia,  inflamma- 
tory overgrowth  of  bone,  etc.  Contractions  of  the  skin, 
ligaments,  and  fasciae  will  also  produce  deformity  which  is 
often  severe ;  and  the  opposite  condition  of  these  parts, 
viz.,  relaxation  through  deficient  support,  may  lead  to  the 
production  of  various  distortions.  Disease  of  the  nerve 
centres  and  nerves,  whether  irritative,  causing  spasm  and 
contraction,  or  paralytic,  is  a  not  infrequent  cause  of  such 
cases  as  the  orthopaedic  surgeon  has  to  treat. 

Among  the  causes  due  to  the  nervous  system  we  have 
both  classes,  the  congenital  and  the  acquired.  These  may 
lead  either  to  active  spasm,  or  passive  contraction  of  the 
muscles.  The  causes  producing  the  former  are  lesions  of 
the  nerve  centres  or  trunks,  which  may  be  direct  or  reflex. 
Among  the  latter  are  some  forms  of  congenital  club-fool , 
and  the  acquired  forms  which  are  more  or  less  due  to 
unbalanced  action  of  opposing  muscular  groups,  as  also 
are  the  various  paralytic  deformities,  the  distortion  occur- 
ring towards  the  side  on  which  the  muscles  are  active.  The 
muscles  themselves  may,  through  injury,  disease,  or  long 
rest  in  an  abnormal  position,  produce  various  degrees  of 
deformity. 

B    2 


4  BODILY    DEFORMITIES. 

Acquired  deformities  due  to  cerebral  mischief  are 
generally  met  with  in  orthopaedic  practice  in  the  stage  of 
secondary  rigidity,  as  in  cases  of  hemi-  or  paraplegia. 
This  condition  appears  to  be  due  to  degeneration,  passing 
down  the  cord  from  the  seat  of  brain  lesion  and  along  the 
pyramidal  tracts.  In  cases  of  hemiplegic  rigidity,  the 
shoulder  is  raised  and  each  arm  held  firmly  to  the  side, 
the  elbow  and  wrist  are  flexed  and  the  fingers  clenched, 
while  the  leg  is  in  the  opposite  condition  of  extension,  the 
knee  being  straight  and  the  toes  turned  towards  the  ground. 
In  such  cases  all  or  most  of  the  muscles  are  involved  in  the 
spastic  condition,  as  proved  on  passive  motion,  though  it 
would  seem  at  first  sight  as  if  only  the  flexors  of  the  upper, 
and  the  extensors  of  the  lower  limb  were  affected.  Infan- 
tile hemiplegia  is  commonly  due  to  a  cortical  lesion,  and 
instances  of  congenital  hemiplegia  are  pathologically 
similar ;  and,  as  secondary  descending  degeneration  of 
the  pyramidal  tracts  occurs  in  these  cases,  rigidity  of  the 
affected  limbs  is  almost  always  present. 

Spinal  spastic  rigidity  is  usually  accompanied  with  motor 
paralysis  in  the  limbs,  and  extreme  muscular  spasmodic 
rigidity,  which  is  not  relaxed  during  sleep.  The  limbs  may 
be  either  flexed  or  extended,  and  in  some  instances  there 
may  be  alternations  of  these  positions.  The  malady  is  due 
to  fibrous  hardening  or  cirrhosis  of  the  lateral  columns ; 
but  there  are  mixed  cases  in  which  these  columns  are  more 
or  less  affected  in  union  with  some  other  part  of  the  cord, 
as  in  the  stiffness  sometimes  found  in  paraplegia  from 
spinal  osteitis. 

Hysterical  spasm  is  of  importance  from  a  diagnostic  and 
therapeutic  point  of  view.  It  may  affect  any  part  of  the 
body,  but  especially  the  limbs,  the  lower  more  often  than 
the  upper,  and  it  may  involve  one  set,  or  various  groups 
of  muscles,  or  the  entire  limb.      Some  of  these  contrac- 


INTRODUCTORY    OBSERVATIONS.  5 

tions  are  quite  extreme,  and  even  under  an  anaesthetic  they 
are  not  always  reduceable  ;  but  this  generally  occurs  in 
cases  of  long  standing,  in  which  shortening  of  the  muscles 
has  taken  place.  Sir  James  Paget's  Clinical  Lectures,  and 
the  little  work  by  Dr.  Shaffer  of  New  York  on  "  The 
Hysterical  Element  in  Orthopaedic  Surgery"  may  be  ad- 
vantageously consulted  from  a  clinical  point  of  view. 


Fig.  i. — Left  improper  writing  position  in  a  girl. 

Reflex  spasm  is  rarely  of  a  permanent  nature.  It  may 
be  due  to  the  irritation  of  worms,  which  may  cause  squint- 
ing in  children,  or  it  may  be  due  to  dental  inflammation, 
or  to  facial  neuralgia.  In  the  limbs,  permanent  contrac- 
tion arising  from  this  cause  is  quite  exceptional.  Chronic 
torticollis  and  strabismus  may  be  reflex  or  direct,  and  in 
the  latter  case  the  pathology  is  not  yet  clearly  made  out. 


6  BODILY   DEFORMITIES. 

The  conditions  producing  passive  non-spasmodic  muscu- 
lar contraction  will  be  found  sufficiently  given  in  the 
sections  on  causes  in  the  various  chapters  in  this  work. 

Prophylaxis  of  Deformities.— This  can,   of  course 
only  apply  to  acquired  distortions,  and  consists  in  the  pre- 
vention of  abnormal  positions  in  the  spine  and  limbs  when 
enfeebled  or  diseased.     It  may  be  general  or  local.     The 


Fig.  2. — Right  vicious  writing  position  in  a  boy. 


former  consists  in  preserving  and  improving  the  health  by 
all  known  means  :  as  by  good  air,  sufficient  exercise  and 
rest,  morning  baths,  good  nourishing  food,  regular  meals,  a 
proper  mode  of  dress,  and  other  well-known  hygienic 
means. 

The  latter,  as  regards  the  spine,  consists  in  seeing  that 
children,  and  especially  girls,  do  not  assume  vicious  positions 


INTRODUCTORY    OBSERVATIONS.  7 

in  sitting  or  standing,  and  that  while  writing  or  studying  at 
school,  an  improper  attitude  be  not  adopted,  and  become 
habitual.  Weight-bearing  in  young  growing  folk,  especially 
if  on  one  side,  is  very  prejudicial.  The  accompanying 
figures  show  improper  and  correct  positions  in  writing. 

Work  and  play  should  be  judiciously  intermixed,  and 
out-door  games,  swimming,  &c,  for  both  sexes  are  very 
beneficial  for  the  due  development  of  all  the  muscles  and 
viscera.  Gymnastics,  general  and.  local,  are  valuable  adjuncts 
in  the  prevention  and  treatment  of  deformities. 

The  recent  conferences  at  the  Health  Exhibition  have 
only  resulted  in  the  repetition  of  old  truths,  as  this  subject 
has  been  thoroughly  worked  out  long  ago  ;  but,  perhaps, 
the  repetition  of  old  knowledge  may  do  good.  Sir  James 
Paget's  objection  to  gymnastics,  as  a  means  of  developing 
the  body,  seems  to  me  a  mistaken  one ;  and  we  need  go 
no  farther  than  Germany — unless  we  would  revert  to  ancient 
Greece — to  prove  the  individual  and  national  value  of  this 
excellent  means  of  developing  our  physical  powers. 

In  the  limbs,  prophylaxis  consists  in  so  ordering  habits 
of  standing,  and  in  so  treating  injuries  and  diseases  of  the 
joints  and  bones,  as  to  prevent  deformity,  or  minimise  its 
effects  if  inevitable.  Large  scars  resulting  from  burns  must, 
by  attention  to  position,  and  by  skin  grafting,  be  prevented 
from  producing  distortion. 

General  Remarks  on  Orthopaedic  Therapeutics. 
— The  principles  are  few  and  very  intelligible,  and  are 
these  : — 

i.  To  remove,  if  possible,  the  cause  of  the  deformity. 

2.  Correction  of  the  deformity  through  changing  the 
position  of  the  distorted  bones,  or  through  extension  of 
contracted  muscles  and  ligaments,  or  by  division  and 
subsequent  extension  of  retracted  muscles  or  their 
tendons. 


BODILY    DEFORMITIES. 


3.  To    maintain    the   improved    position   and    prevent 
relapse. 


Under  the  first  head  come  all  those  precautions  as  to 
correcting  bad  habits  of  position  in  early  life,  and  after- 


INTRODUCTORY    OBSERVATIONS.  9 

wards,  in  occupations.  Miners'  lateral  curvature,  and 
bakers'  flat  foot,  are  instances  of  deformity  produced  by 
improper  vocational  positions,  and  by  long  standing  and 
carrying  heavy  weights.  In  the  limbs,  fractures  should  be 
so  set,  and  diseased  joints  proceeding  to  anchylosis  so 
regulated,  as  to  obviate  deformity  as  much  as  possible, 
and  to  allow  the  limb  to  become  fixed  in  a  serviceable 
position. 

The  details  of  the  second  head  will  be  found  in  the 
various  chapters  of  this  work.  They  may  here  be  summed 
up  by  saying  that  they  consist  in — i.  Bodily  movements, 
active  and  passive  ;  2.  Improvement  of  the  general  health; 
3.  Mechanical  means,  and  by  operative  methods.  These 
require  no  further  explanation  than  will  be  met  with  in  the 
following  pages. 

Under  the  third  head  are  included  the  supervision  of  the 
case,  the  continuance  of  local  and  general  measures  used 
in  the  correction  of  the  deformity,  and  the  regular  and 
judicious  exercise,  in  its  normal  functions,  of  the  part 
which  has  been  restored  to,  or  near  to,  its  proper  shape. 


IO  BODILY   DEFORMITIES. 


CHAPTER  II. 

RICKETS    SURGICALLY    CONSIDERED. 

Definition. — Rickets  is  a  peculiar  constitutional  malady, 
manifesting  itself  chiefly  in  the  osseous  system.  As  so 
many  of  the  deformities,  especially  those  of  the  lower 
limbs,  are  due  to  this  condition,  a  work  on  orthopaedics 
would  not  be  complete  without  some  account  of  it  from  a 
surgical  point  of  view. 

Synonyms. — Latin,  Rachitis;  morbus  Anglicus ;  Greek, 
paxins-voaos  =  a  spinal  complaint  ;  German,  die  Englische 
Krankheit ;  Doppelglieder  ;  Zwiemuchs  ;  Rhachitis  ;  French, 
Rachiiisme ;  maladie  Anglaise.  The  word  rickets  is  probably 
derived  from  the  Saxon  rick,  a  heap  or  hump. 

Varieties. — The  disease  may  be  general  or  partial. 
The  local  form  occurs  more  commonly  in  adolescence  or 
in  later  life.  The  general  disease  occurs  usually  in  infants, 
the  partial  form  more  commonly  in  adolescents.  Its 
manifestations  may  be  acute  or  chronic.  In  practice  we 
meet  with  three  chief  forms  :  (i.)  Infantile  rachitis,  some- 
times, though  rarely,  intra-uterine.  The  infantile  form  is 
by  far  the  commonest;  (2.)  rachitis  of  adolescence,  which 
in  my  experience  is  fairly  common ;  (3.)  senile  rachitis,  of 
which  I  have  seen  some  well  marked  examples  and  drew 
attention  to  the  subject  in  1874.*     Czernyf  has  shown  that 

*  "London  Medical  Record,"  1874,  p.  142,  etc. 
t  "  Wien  Med.  Woch.,"  1873,  No.  39. 


RICKETS    SURGICALLY    CONSIDERED.  II 

a  disease  which  is  practically  rachitis,  but  which  he  termed 
local  osteo-malacia,  may  occur  in  adults,  and  records  the 
case  of  a  soldier,  get.  twenty-two,  whose  left  leg  was  thus 
affected.  Scoutetton*  relates  a  similar  case  occurring  in 
one  leg  of  a  tailor.  Solly  t  relates  two  cases  occurring  in 
males,  both  aet.  thirty.  MosetigJ  relates  a  case  occurring 
in  a  male,  set.  twenty-one,  and  called  it  osteo-halisterisis  = 
partial  decalcification.  He  states  that  the  cartilage  is 
normal.  Weinlechner  §  relates  two  cases  occurring  in  the 
right  legs  of  males  set.  twenty-five  and  eighteen.  The 
case  which  I  recorded  was  certainly  not  osteo-malacia,  and 
it  occurred  in  a  woman,  set.  fifty.  Both  her  legs  were  a  good 
deal  bent,  the  right  began  curving  three  years  before  she 
came  to  the  London  Hospital,  and  the  left  fourteen  months 
before.  Both  tibiae  were  much  curved  anteriorly  and 
slightly  externally.  She  was  under  observation  for  some- 
time and  I  was  at  first  inclined  to  attribute  the  malady  to 
that  condition  which  is  now  better  known  under  the  term 
of  osteitis  deformans.  For  some  months  she  remained 
under  care,  but  the  curvature  did  not  increase  in  the  right 
limb  and  only  slightly  in  the  left,  and  the  pain  first  com- 
plained of  had  disappeared.  She  could  walk  fairly  well 
when  I  lost  sight  of  her.  Though  this  case  is  deficient  in 
pathological  examination,  still,  in  conjunction  with  some 
•others  that  I  have  seen  and  been  able  to  follow  for  some 
time,  I  think  it  not  at  all  unlikely  that  regressive  changes 
were  occurring  in  these  bones  closely  allied  to  rachitic  pro- 
cesses. 

Causes. — This  disease   is    generally  due   to  imperfect 
nutrition,  and  though  insufficient  and  bad  food,  and  bad 

*  "Gaz.  Med.  de  Paris." 

t  "Med.-chi.  Trans."  v.  27,  1884. 

t  "Wien  Med.  Presse,"  1868,  p.  89. 

§  "  Woch.  d.  Gesellschaft  d.  Aerzte  in  Wien,"  B.  25. 


12  BODILY   DEFORMITIES. 

water  are  important  factors,  bad  hygienic  conditions,  such 
as  foul  air,  improper  clothing,  &c,  are  also  active  pro- 
ducers or  inciters  to  the  development  of  the  malady. 
Heredity  is  in  some  cases  strongly  marked,  while  in  others 
I  have  observed  that  several  members  of  the  same  family 
have  become  rachitic  though  the  parents  were  free  from  it. 
Illness  or  debility  of  the  mother  during  child-bearing  has 
an  undoubted  influence  in  producing  the  disease.  Acute 
and  epidemic  diseases,  and  even  chronic  wasting  maladies 
in  children  may  lead  to  the  production  of  bone  curvatures. 
Poverty,  with  its  concomitant  conditions  above  enumerated, 
is  a  powerful  factor,  though  the  disease  is  not  unknown 
among  the  well-to-do,  as  I  have  had  to  treat  several  children 
of  parents  in  good  circumstances.  In  such  cases  it  is  due 
chiefly  to  improper  feeding,  or  to  some  derangement  of  the 
assimilative  organs.  Parrot  thought  that  rickets  was  always 
caused  by  syphilis,  denying  that  it  could  be  produced  arti- 
ficially, though  Baginsky,  RolirT,  and  others,  have  shown 
experimentally  that  the  deprivation  of  lime  from  the  food 
of  animals  would  produce  slight  rachitic  changes,  but  that 
if  lactic  acid  be  added  to  the  food  while  the  lime  salts  be 
withheld,  pronounced  rachitis  results.  Baginsky*  says  that 
the  disturbance  of  the  general  nutrition  happens  at  a  time 
when  the  growth  of  the  bones  is  active,  and  this  is  why  the 
bone  change  is  the  most  prominent  symptom.  Tuber- 
culosis and  scrofula  have  usually  nothing  to  do  with  the 
production  of  rickets,  though  they  may  co-exist. 

Parts  chiefly  affected. — I  have  taken  a  thousand  cases 
as  perhaps  a  sufficient  standard  on  which  to  found  the 
following  general  conclusions,  though  in  the  course  of  seven- 
teen years  surgical  practice  I  have  seen  very  many  more. 
In  these  I  find  that  in  nearly  every  case  the  lower  ends 

*  "Trans.  International  Congress,"  London,  1881. 


RICKETS    SURGICALLY    CONSIDERED.  13 

of  the  radius  and  ulna  were  enlarged,  the  clavicles  were 
curved  in  250,  the  humerus  in  115,  the  radius  and  ulna, 
one  or  both,  in  97.  In  these  cases  of  deformity  of  the 
upper  limb,  the  child  was  in  the  habit  of  crawling  about, 
and  in  the  few  which  the  mother  stated  had  not  done  so, 
the  curvature  was  probably  either  due  to  muscular  action, 
or  to  varying  intensity  of  the  disease  at  different  portions 
of  the  bones.  The  ribs  were  very  commonly  found  beaded, 
and  in  cases  where  the  thoracic  parietes  were  deformed 
they  were  flattened  laterally,  and  the  patient  was  affected 
with  pigeon  breast.  The  spine  was  affected,  i.e.  curved 
latterly,  or  was  kyphotic  or  lordotic  in  210.     Lateral  curva- 


Fig.  5. — Rachitic  deformity  of  forearm.     The  radius  is  acutely  bent  about  its 
middle,  the  lower  end  of  the  ulna  is  enlarged,  and  the  hand  displaced  to  radial  side. 

ture  was  by  far  the  commonest,  then  came  lordosis,  and 
kyphosis  was  the  least  frequent.  The  pelvis  gave  external 
evidence  of  deformity  in  all  the  cases  in  which  the  spine 
was  affected,  though  the  amount  of  deformity  of  course 
differed  in  various  cases.  In  the  few  rachitic  female  adults 
whom  I  have  had  the  opportunity  to  examine,  the  spine 
was  externally  deformed  in  all,  and  three  gave  accounts  of 
difficult  instrumental  labours.  In  the  lower  limbs,  curva- 
tures of  the  leg  bones  and  knock-knees  predominated,  the 
former  being  much  the  more  common.  The  femur  was 
more  or  less  curved  in  300  cases,  and  genu  valgum  or 
general  bowing  of  the  legs  was  present  in  415  cases;  the 


14  BODILY   DEFORMITIES. 

malleoli  were  enlarged  in  394 ;  rachitic  valgus  was  present 
in  294,  and  in  infants  the  fontanelles  were  open  in  755 
cases,  and  closed  in  210. 

Symptoms  and  Diagnosis.— The  patient  is  usually  out 
of  health  with  deficient  appetite,,  the  temperature  is  raised, 
and  there  may  be  drowsiness.  The  bowels  may  be  confined, 
or  there  may  be  loose  greenish  stools  of  a  very  offensive 
odour.  These  symptoms  may  lead  to  confounding  the 
disease  with  the  early  stages  of  some  exanthems,  or  with 
intestinal  catarrh,  with  infantile  remittent,  or  with  the 
reflex  irritation  of  teething,  which,  however,  is  not  generally 
retarded  as  would  be  expected  in  this  disease.  Usually 
there  is  profuse  perspiration  of  the  head  and  upper  portion 
of  the  body,  and  a  general  tenderness  of  the  limbs  and 
trunk.  The  abdomen  is  often  prominent  at  a  later  stage, 
when  the  shafts  and  ends  of  the  long  bone  are  also  very 
sensitive  to  manipulation.  The  ribs  will  soon  be  found  to 
be  markedly  beaded,  and  the  chest  will  be  observed  to 
be  smaller,  and  the  respiration  more  rapid.  If  kyphosis 
be  early  developed,  the  tenderness  along  the  spine  may 
lead  to  the  supposition  of  caries,  but  if  the  child  be  lifted 
by  the  surgeon  grasping  the  axillae,  the  deformity  will  dis- 
appear if  due  to  rickets ;  but  in  early  stages  of  caries  I 
have  seen  spinal  rigidity  disappear  when  extension,  after 
the  manner  described,  has  been  kept  up  a  few  minutes.  It 
must  be  borne  in  mind  that  caries  and  rickets  may  co- 
exist. 

As  soon  as  the  child  attempts  to  walk,  it  will,  in  many 
cases,  be  found  that  it  tumbles  about,  and  children  are 
commonly  brought  because  they  are  backward  in  walking  ; 
should  they  be  strong  enough  to  bear  the  weight  of  their 
body,  they  totter  along,  and  the  bones  of  the  lower  limbs 
soon  become  curved ;  but  in  other  cases,  curvature  occurs 
some  time  after  the  child  has  commenced  walking.     So- 


RICKETS    SURGICALLY   CONSIDERED.  1 5 

called  growing  pains  are  often  observed  in  various,  parts  of 
the  body,  and  especially  in  the  limbs  :  most  markedly  so 
about  the  knee-joint.  These  pains  in  the  lower  limbs  are 
sometimes  so  severe  that  they  may  be  mistaken  for  com- 
mencing ostitis  or  arthritis,  and  if  the  child  has,  as  is  not 
uncommon,  had  a  fall,  the  surgeon  may  be  deceived  into 
regarding  the  case  as  due  to  injury  to  the  bones  or  joint. 
Greenstick,  or  rachitic  fractures,  commonly  occur  after 
comparatively  slight  accidents. 

Pathology.— As  the  orthopaedic  surgeon  has  to  do  with 
the  correction  of  deformity,  it  is  only  necessary  here  to 
record  what  is  at  present  known  of  the  changes  in  the  bones 
only.  These  have  been  divided  into  three  stages.  In  the 
first  there  is  rarefaction  and  effusion,  and  the  bones 
generally,  and  especially  the  long  bones,  are  infiltrated  with 
a  blackish  bloody  matter ;  but  there  is  not  as  yet  any 
external  deformity,  though  the  osseous  tissue  is  rarefied 
and  softened,  and  can  be  easily  cut. 

In  the  second  period  the  deformity  begins,  and  there  is 
swelling  of  the  epiphysis,  and  curvature  of  the  diaphysis. 
The  former  is  due  to  the  presence  of  a  spongy  cartilagin- 
ous tissue,  the  histological  characters  of  which  must  be 
sought  in  the  various  works  on  surgical  pathology.  The 
latter  are  caused  by  changes  in  the  compact  tissue  of  the 
diaphysis,  which  become  more  and  more  spongy,  and  at  a 
late  stage  become  converted  into  thin  friable  concentric 
layers,  separated  from  each  other  by  a  soft  and  vascular 
connective  tissue. 

In  the  third  stage,  if  the  patient  survive  the  rachitic 
marasmus,  the  bones  become  consolidated  and  eburnated, 
so  that  the  bone  is  much  more  dense  than  that  of  the 
former  compact  tissue.  Deformities  of  the  spine,  pelvis, 
thorax,  &c,  which  have  appeared  in  the  second  stage,  now 
become  fixed,  and  if  seen  at  this  period  they  are  usually 


i6 


BODILY    DEFORMITIES. 


found  to  be  beyond  surgical  correction ;  but  it  is  quite 
otherwise  in  deformities  of  the  limbs.  In  the  upper  limbs, 
the  curvature  does  not  usually  interfere  with  the  usefulness 
of  the  member,  though  in  some  instances  severe  deformity 
may  be  rectified  with  advantage  to  function ;  but  in  the 
lower  limbs,  the  body-weight  often  produces  great  deformity, 


Figs.  6  and  7. — Severe  rachitic  deformity  of  lower  limbs.      Anterior  and  lateral 
views.     From  casts  in  the  London  Hospital  Museum. 


which  seriously  interferes  with  the  appearance  and  locomo- 
tion of  the  individual.  In  children  from  three  to  five  years 
of  age,  the  deformity  is  usually  limited  to  certain  bones,  such 
as  the  leg  bones  and  femur  ;  but  in  older  children,  and  in 
adolescents,  it  manifests  itself  at  the  epiphyses,  which  be- 


RICKETS    SURGICALLY   CONSIDERED.  1 7 

come  joined  to  the  shaft  at  a  later  period  in  life,  such  as 
the  lower  epiphyses  of  the  femur  and  upper  of  the  tibia. 

In  addition  to  the  general  changes  in  the  bones  and 
cartilages,  already  described,  it  will  be  observed  that  if  a 
section  be  made  through  the  length  of  a  long  bone,  the 
medullary  canal  will  be  found  contracted  at  the  middle 
portion  of  the  bone,  and  enlarged  at  its  ends.  Sometimes  it 
is  dilated  in  its  whole  extent,  and  in  other  instances  it  is 
prolonged  up  to  the  epiphyses.  In  bad  curvatures  it  is  no 
longer  central,  but  nearer  the  convexity  of  the  bone,  being 
only  separated  from  its  surface  by  a  thin  layer  of  compact 
tissue,  or  it  may  often  communicate  with  its  surface.  On 
the  concave  side  the  bone  increases  considerably  in  thick- 
ness by  the  formation  of  new  sub-periosteal  layers,  which 
Virchowhas  termed  osteoid  tissue. 

Prognosis.— This  has  reference  to  the  age  of  the  patient, 
and  to  the  probability  of  rectifying  the  deformity.  It  is  only 
in  infants  and  quite  young  children,  and  in  the  severe  and 
acute  forms  of  the  disease,  that  a  fatal  result  has  to  be 
feared,  either  through  marasmus,  or  some  of  the  well-known 
complications  of  the  disease.  After  this  period,  and 
provided  that  thoracic  deformity  be  not  so  extreme  as  to 
interfere  with  the  functions  of  the  heart  and  lungs,  there  is 
no  risk  to  life.  Patients  may  live  to  a  ripe  old  age  though 
much  deformed.  As  regards  the  correction  of  rachitic 
deformity,  the  brilliant  results  of  bone  surgery  of  the  last 
few  years  permit  us  to  promise  very  much  to  the  patients. 
We  can  often,  in  the  second  stage,  by  correct  general  and 
local  treatment,  not  only  prevent  deformity,  but  straighten 
bones  which  are  already  bent  or  bending,  by  manual  and 
instrumental  means  without  operation ;  and  in  the  third 
stage,  we  can  by  osteotomy  or  osteoclasy,  fracture  the  limbs 
and  reset  them  in  a  proper  position ;  so  that  the  prognosis, 
as  regards    deformity  is,  in  the  large  majority  of  cases, 

c 


BODILY   DEFORMITIES. 


very  favourable,  but  it  must  be  borne  in  mind  that  secondary- 
deformities  may  result,  as  shown  in  the  annexed  figure, 
where  the  lateral  curvature  was  not  rachitic  in  origin,  but 
due  to  a  long  standing  rachitic  genu  valgum.      Hence  the 


Fig.  8.— Lateral  curvature  in  a  girl  aged  fifteen,  secondary  to  old  genu  valgum. 

importance  of  correcting  deformities  of  the  lower  limbs  as 
soon  as  possible. 

Treatment— This  is  divisible  into  general  and  local ; 
the  former  consists  in  removing  any  of  the  bad  hygienic 
surroundings  of  the  patient,  and  in  the  adminstration  of 
proper  diet  and  medicines  :  such  as  cod  liver  oil,  and  lime 


RICKETS    SURGICALLY    CONSIDERED.  IQ 

salts.  Kassowitz  has  recently  stated  that  phosphorus,  one 
part  in  10,000  of  olive  or  cod-liver  oil,  will  cause  craniotabes 
to  disappear  in  from  four  to  eight  weeks,  and  that  laryngeal 
spasm  in  cranial  rickets  becomes  less  frequent  in  a  few 
days,  and  ceases  in  a  few  weeks.  Also  that  marked  lateral 
curvature  disappears  in  a  few  months,  and  that  children 
who  for  years  have  not  been  able  to  stand,  will  in  the 
course  of  one  or  two  months  be  able  to  support  themselves 
and  walk  about.  If  these  statements  prove  even  approxi- 
mately correct,  a  great  therapeutic  advance  will  have  been 
made. 

Disorders  of  the  digestive  apparatus  are  often  relieved 
by  grey  powder  in  small  doses.  If  cod-liver  oil  cannot 
be  taken  it  may  be  rubbed  in.  Flannel  or  wool  garments 
should  be  worn  next  the  skin,  and  the  children  may  be  daily 
bathed  in  tepid  sea-salt  and  water,  or  in  sea  water.  In  the 
second  stage,  as  well  as  in  the  first,  the  patient  should  be  kept 
as  much  as  possible  in  the  lying  position,  so  as  to  prevent 
deformity  of  the  limbs  through  the  body  weight.  In  many 
of  these  cases,  well  padded  and  properly  applied  splints  will 
enable  the  children  to  take  some  exercise  and  get  into  fresh 
air,  which  is  an  undoubted  advantage  ;  but  if  after  a  trial  of 
these  means,  the  deformity  show  signs  of  increase,  absolute 
rest  should  be  enjoined,  and  especially  in  girls,  as  standing 
and  walking  in  them  may  produce  pelvic  deformities  which 
may  give  trouble  in  later  life  during  parturition ;  but  it 
must  be  recollected,  as  Mr.  J.  Wood  has  pointed  out,* 
that  even  in  the  recumbent  posture  the  pelvis  may  become 
deformed  if  it  be  much  softened.  In  boys,  progression 
may  be  allowed  much  more  freely  than  to  girls,  provided  the 
limb  deformity  is  not  increasing,  for  any  resulting  deformity 
of  the  pelvis  is,  in  them,  not  usually  a  serious  matter.     In 

*  Article— Pelvis,  Todd  and  Bowman's  "Encyclopedia  of  Anatomy 
and  Physiology." 

C    2 


20  EODILY    DEFORMITIES. 

patients  whose  parents  can  afford  a  light  and  effective 
apparatus,  extending  from  the  pelvis  to  the  boot,  I  think 
the  results  are  far  better  than  with  the  use  of  ordinary  side- 
splints  ;  but  even  with  the  latter  we  may  not  infrequently 
achieve  considerable  success,  though  it  must  not,  in  this 
connection,  be  forgotten  that  a  certain  small  percentage  of 
cases  become  perfectly  straight  without  the  use  of  any 
retentive  apparatus. 

In  the  third  stage,  that  of  consolidation,  operative  inter- 
ference is  the  only  mode  for  correction  of  the  deformity, 
and  here  the  question  of  choice  is  between  osteotomy  and 
osteoclasy.  These  are  sufficiently  discussed  in  a  later 
part  of  this  book.  As  to  the  age  in  which  it  is  necessary 
to  operate,  my  experience  is  that  age  of  itself  is  no  certain 
guide,  the  best  test  being  the  condition  of  the  bones.  I 
have  seen  many  children  between  three  and  four  with 
firmly  set  bones,  and  have  had  great  difficulty  in  penetrating 
them  with  a  chisel,  while  in  some  others  from  five  to  ten 
years  of  age  the  bones  have  been  a  good  deal  softer.  I 
am  guided  by  the  state  of  the  bones,  and  the  amount  of  the 
deformity ;  and  in  seeing  cases  for  the  first  time  I  usually, 
as  a  matter  of  routine,  advise  the  trial  of  splints,  but  if  not 
enough  beneficial  change  result  in  two  or  three  months,  I 
at  once  resort  to  operation. 


21 


PART    II. 

DEFORMITIES    OF    THE    SPINE   AND 
TRUNK. 


CHAPTER   III. 

EXAMINATION    OF    THE    SPINE. 


Essentials  of  Spinal  Anatomy.  —  The  Spi?ie  is  a 
flexible  and  strong  column  susceptible  of  various  move- 
ments, and  acts  as  the  column  of  support  to  the  head  and 
upper  limbs,  and  transmits  their  weight,  as  well  as  that  of 
the  head,  neck,  thoracic  and  abdominal  viscera,  through 
the  pelvis  to  the  lower  limbs.  The  ribs  are  attached  to  it, 
and  numerous  muscles  are  connected  with  the  vertebral 
processes  and  bodies  which  help  to  form  it,  and  the  function 
of  this  arrangement  of  numerous  joints  and  muscles,  is  to 
give  great  mobility  combined  with  firmness,  and  with  the 
aid  of  the  ligaments,  to  fix  it  for  any  desired  purpose. 
The  elasticity  of  the  vertebral  column  is  due  to  the 
intervertebral  discs,  and  to  the  spinal  curves,  which,  if  seen 
from  the  side,  present  a  cervical  and  lumbar  anterior 
curvature,  and  a  dorsal  and  sacral  posterior  curve.  These 
vary  somewhat  in  different  individuals,  and  are  due,  in  part, 
to  the  varying  shape  of  the  vertebral  bodies,  or  intervertebral 


2  2  BODILY    DEFORMITIES. 

discs.  At  birth  these  curvatures  do  not  exist,  but  as  the 
child  begins  to  sit,  or  stand  and  walk,  these  begin  to  be 
formed.  There  is,  however,  a  general  posterior  curvature 
when  infants  are  supported  on  their  buttocks,  but  this  is  due 
to  spinal  weakness,  and  the  inability  of  the  child  to  hold 
itself  erect.  The  intervertebral  discs  are  twenty-three,  and 
form  nearly  a  fourth  of  the  whole  length  of  the  spine.  If 
they  be  removed,  and  the  vertebrae  articulated,  the  cervical 
and  lumbar  anterior  curvatures  nearly  vanish,  and  the 
spine  appears  to  present  but  one  great  posterior  curvature, 
the  most  prominent  part  of  which  is  just  below  the  middle 
dorsal  region,  and  resembles,  not  a  little,  in  shape  what  one 
has  observed  in  senile  cyphosis,  which  latter  is  probably 
due  to  shrinking,  or  other  pathological  changes  of  the 
intervetebral  substances.  These  discs  are  highly  compres-. 
sible,  losing  about  three-quarters  of  an  inch  during  the  day- 
time, but  recumbency  from  six  to  eight  hours,  allows  them 
.to  again  become  extended. 

The  movement  of  the  spinal  column  is  most  extensive  in 
the  cervical  and  lumbar  regions,  and  in  the  latter,  motion  is 
freest,  consisting  of  anterior  and  lateral  flexion,  extension, 
and  some  rotation.  In  the  neck,  antero-posterior  flexion  is 
not  so  free  as  in  the  loins,  though  lateral  flexion  and 
rotation  are  greater.  The  spinal  ligaments,  especially  the 
ligamenta  subflava,  which  unite  the  laminae,  assist  in  main- 
taining the  natural  spinal  positions.  The  ligaments  just 
mentioned  are  stretched  during  flexion,  and  help  to  restore 
the  spine  to  the  erect  position  during  extension,  but  there 
can  be  little  doubt  that  the  muscles  are  the  active  structures 
in  maintaining  the  spine  erect,  though  whether  by  active 
tension,  or,  as  Mr.  Adams  has  it,  by  vigilant  repose,  is  not 
yet  thoroughly  established.  As  regards  the  production  of 
the  different  forms  of  lateral  curvature,  there  can  be  no 
question  that  muscular  action,  or  lack   of  it,   has  been 


SPINE    AND    TRUNK. 


23 


exaggerated,  and  too  little  attention  paid  to  the  condition 
of  the  bones,  intervertebral  substances,  and  statical  condi- 
tions in  the  production  of  these  deformities. 

Examination  of  the  Spine —This  is  done  by  inspec- 
tion, palpatio?i  and  mensuration.  The  patient  should  be 
nude  to  just  below  the  iliac  crests,  and  should  be  placed 
so  that  the  light  falls  upon  his  or  her  back,  and  may  be 
examined  in  the  erect  and  sitting  postures.  In  the  former, 
the  heels  should  be  touching  and  the  toes  slightly  everted, 
the  head  held  straight,  and  the 
arms  hanging  naturally  at  the 
sides ;  the  surgeon's  eye  having 
observed  the  chief  deviations,  his 
finger  should  then  be  passed 
down  the  course  of  the  spinous 
processes,  and  if  this  be  done 
two  or  three  times,  a  red  line  will 
appear  giving  a  tracing  of  the 
curves  formed  by  them.  In 
severe  cases  of  rotation,  care 
should  be  taken  not  to  confound 
the  apices  of  the"  transverse  with 
those  of  the  spinous  processes. 

This  being  done,  the  patient 
should    be    made    to    gradually 

StOOp  forwards,    and  tO  bend  the      Fig.  9.— Diagram  of  the  normal 
1    z.         11  u~4-U    A;~~^4-;^„r,    posterior    aspect    of   a  well-formed 

spine  laterally  in  both  directions,  ^  trunkp 
as  by  these  motions  any  altera- 
tion of  the  curvature  will  be  noticed.     If  necessary,  the 
patient  may  be  requested  to  lie  in  a  prone  position,  and 
the  spinous  apices  again  traced  to  see  if  prone  recumbency 
make  any  difference. 

The  accompanying  figures  will  serve  as  useful  guides  to 
the  surgeon.     Fig.   9  shows  the  normal    position  of  the 


24  BODILY   DEFORMITIES. 

shoulders,  lower  angles  of  scapulas,  iliac  crests  and  fold  of 
buttocks,  which,  and  especially  the  first  three,  become 
altered  in  relation  in  spinal  curvatures. 

Fig.  10  will  be  found  serviceable  in  diagnosing  which  verte- 
brae are  affected  in  Pott's  disease,  and  if  it  be  recollected 
that  the  spine  of  the  fifth  lumbar  vertebra,  is  a  little  below  a 


Fig.  io. — Diagram  of  the  vertebra  from  behind. 

line  joining  the  highest  points  of  the  iliac  crests,  and  if  the 
surgeon  count  upwards,  no  difficulty  should  arise.  The  last 
rib  will,  if  followed  obliquely  upwards,  guide  to  the  twelfth 
dorsal,  and  the  vertebra  prominens  is  the  landmark  to  the 
lower  limit  of  the  cervical  portion  of  the  spine. 

I  have  so  frequently  observed  how  inaccurately  cases  are 


SPINE    AND    TRUNK. 


25 


recorded,  being  simply  registered  as  lateral  curvature,  or 
Pott's  disease,  without  any  indication  as  to  the  exact  seat 
of  the  deviation,  that  for  the  purpose  of  surgical  accuracy, 
I  have  inserted  the  above  figures  and  explanation. 

These  methods  will  indicate  to  us  the  nature  and  situation 
of  the  chief  curve,  and  of  a  secondary  one  if  present ;  but 
for  the  accurate  observation  of  the  effect  of  treatment  it 
is  necessary  to  have  some  reliable  record,  or,  in  other  words, 
to  measure  the  amount  of  the  deformity.  For  this  purpose 
various  means  and  apparatus  have  been  devised,  the 
simplest  of  which  appears  to  be  to  allow  a  plumb-line  to 
hang  from  the  region  of  the  upper  cervical  vertebrae,  and 
a  slight  deviation  from  this  right  line  will  soon  become 
apparent,  and  can  be  measured  by  an  ordinary  rule,  and  re- 
corded ;  but  to  be  more  accurate  we  can  take  a  tracing  by 
means  of  the  apparatus  illustrated  in  the  annexed  figure,  or 
we  can  measure  accurately  by  Mikulicz's  Skoliosometer.  * 

Biihring's  apparatus  consists  of  a  glass  plate  16  inches 
by  20  inches,  fixed  in  a  moveable  frame  attached  to  two  up- 
rights; the  plate  is  divided  into  half-inch  squares,  and  from 
the  centre  of  the  upper  part  of  the  frame,  a  plummet-line  is 
suspended.  At  the  side  of  the  uprights,  there  is  an  arrang-e- 
ment  to  grasp  the  arms  of  the  patient  at  the  deltoid 
insertions,  and  at  its  lower  part  is  a  horizontal  projection 
upon  which  a  moveable  dioptor  is  fixed  upon  a  vertebral 
staff.  This  simple  instrument  is  placed  towards  the  light 
with  the  patient  behind  it,  and  the  glass-plate  is  adjusted  so 
as  to  cover  the  entire  trunk.  The  arms  of  the  patient  are 
then  fixed,  and  the  patient  is  made  to  stand  with  his  spine 
in  the  mid-line  of  the  plate  and  with  his  heels  together.     A 

*  Last  winter  an  instrument  termed  a  spinometer  was  shown  at  a 
meeting  of  the  Manchester  Medical  Society,  but  no  description  of  it 
appears  to  have  been  published.  The  term  is  objectionable.  Rachio- 
meter  would  be  better. 


26 


BODILY   DEFORMITIES 


tracing  of  his  back  should  now  be  made  with  some  soft 
crayon  chalk,  or  ^  with  some  paint  on  a  brush,  and  the 
plummet  line  is  then  allowed  to  drop  from  the  seventh 
cervical  vertebra,  and  by  using  the  dioptor,  the  spinal 
curvatures  and  their  deviations  from  the  plummet  line  can 

be  accurately  noted.  The  patient  is 
then  released,  and  a  piece  of  paper 
the  size  of  the  glass  plate  is  put  upon 
it,  and  a  tracing  made,  and  this  can 
be  kept  for  reference  with  any 
further  tracings  which  the  progress 
of  treatment  renders  necessary.  This 
plan,  though  giving  the  surgeon 
some  trouble,  is  far  less  expensive 
and  less  irksome  to  the  patient  than 
the  plan  which  was  in  use  before  it, 
of  taking  plaister  moulds  continu- 
ally, or  of  taking  repeated  photo- 
graphs. 

Mikulicz's  Skoliosometer*  is  an 
improvement   on  that   of   Buhring 
Fig.  ii— Bahring's apparatus,  and  Heinecke,  as    these   had  two 

serious  drawbacks  for  practical 
purposes ;  they  were  too  complicated,  and  required  too 
much  time  and  trouble  to  be  used  in  ordinary  practice, 
and  they  did  not  give  reliable  results  in  the  various  forms 
of  scoliosis.  They  only  gave  the  deviation  of  the  spinous 
processes  from  the  midline,  but  not  a  real  idea  of  the 
actual  deviation  of  the  vertebrae,  whereas  Mikulicz's  mea- 
sures the  torsion  as  well  as  the  secondary  thoracic  de- 
formity. The  methods  of  Barwell  and  Sayre,  by  taking 
a  sort  of  mould  with  a  strip  of  lead,  are  subject  to  various 

*  Skoliosometer,  ein  Apparat  zur  Messung  der  Skoliose  :  J.  Mikulicz. 
Centralblatt  fur  Chirurgie,  No.  20,  1883. 


SPINE   AND    TRUNK. 


27 


inaccuracies.  With  Mikulicz's  apparatus  one  may  measure 
— 1.  The    height  of  the   spine.     2.  Its   lateral  deviation. 

3.  Vertebral  torsion  with  reference  to   the  whole  thorax. 

4.  The  position  of  the  scapulae.  5.  The  height  of  the 
shoulder,  and  6,  that  of  the  iliac  crests.  It  consists 
(see  Fig.)  of  a  vertical  portion  BB  and  a  horizontal  CC,  the 
latter  moving  upon  the  former. 

The  vertical  portion  is  fixed  to  a 
metal  arrangement  BA,  and  to 
this  is  fixed  a  pelvic  band  GG. 
At  A  is  a  horizontally  placed 
goniometer,  and  the  portion  BB 
is  attached  below  to  BA,  and  is 
so  arranged  that  it  can  turn  on  a 
vertical  axis  to  1800.  M  is  the 
indicator.  If  this  apparatus  be 
applied  to  a  well-formed  indi- 
vidual the  indicator  will  appear 
at  900,  but  every  torsion  of  the 
body  produces  a  deviation  which 
may  be  read  off  on  the  indicator. 
To  measure  lateral  deviation 
the  apparatus  should  be  applied 
as  in  the  figure.    The  pelvic  band 

should  pass  above  the  trochanters,  and  the  portion  BA  be 
actually  placed  on  the  middle  of  the  sacrum ;  but  if  the 
pelvis  be  obliquely  placed,  the  whole  apparatus  permits  of 
a  rotation  on  a  horizontal  axis,  so  that  in  every  case  the 
vertical  portion  BB  can  be  brought  into  the  position  of  the 
spinal  column.  The  deviation  of  the  pelvis  from  the  hori- 
zontal in  such  a  case  can  be  measured  with  accuracy  by  the 
goniometer ;  but  it  is  easier  to  do  away  with  pelvic  obliquity 
by  putting  something  underneath  the  leg  which  produces 
it.     The  apparatus  being  applied,  one  then  measures  the 


Fig.   12. — Mikulicz's  Skolios- 
ometer  applied. 


2  8  BODILY    DEFORMITIES. 

distance  between  two.  definite  vertebrae  of  the  upper  and 
lower  portions  of  the  column,  by  means  of  the  vertical  BB. 
The  best  fixed  points  are  the  seventh  cervical,  and  the  first 
sacral.     The  lateral  deviation  should  now  be  measured. 

Before  applying  the  apparatus  in  a  case  of  lateral  curva- 
ture, an  ink  or  chalk  mark  should  be  traced  along  the  deviated 
spinous  processes  ;  then  the  instrument  may  be  applied, 
and,  if  the  convexity  be  right  dorsal,  as  is  commonest,  the 
apparatus  should  be  pushed  slightly  to  the  left,  so  that  the 
right  edge  of  the  vertical  piece  BB  corresponds  actually  to 
the  mid-line,  that  is  to  say,  with  the  spinous  processes  of 
the  seventh  cervical  and  first  sacral  vertebrae.  With  the 
aid  of  the  horizontal  part  CC,  one  may  now  read  off  the 
deviation  of  the  vertebrae  at  the  most  prominent  part  of 
the  curve.  If  the  convexity  be  to  the  left,  the  apparatus 
should  be  shifted  slightly  to  the  right,  and  applied  in  the 
manner  just  described.  For  practical  purposes  it  suffices 
to  note  the  number  of  the  vertebrae  affected,  and  the 
deviation  of  the  spinous  processes  where  the  curve  is 
greatest.  One  must  also  observe  the  relative  position  of 
those  vertebrae  which  lie  between  the  primary  and  com- 
pensatory curves,  and  correspond  accurately  to  the  mid- 
line, and  these  vertebrae  Mikulicz  calls,  the  resting-vertebree. 

The  torsion  of  the  vertebra  must  now  be  measured.  In 
the  previous  measurements  the  arms  were  allowed  to  hang 
by  the  side,  but  now  both  arms  must  be  raised,  and  crossed 
over  the  head  as  this  raises  the  scapulae,  and  the  form  of 
the  thorax  is  made  clearer.  The  horizontal  part  CC  is 
now  placed  at  various  heights  accurately  on  the  back,  and 
the  deviations  in  the  sense  of  torsion  are  then  shown  by 
the  indicator  M,  but  one  must  make  sure  previously  that 
the  metal-plate  corresponds  accurately  to  the  frontal  plane, 
for  if  the  body  be  oblique  the  plate  will  rotate  on  a  vertical 
axis,  and  the  indicator  will   mark  wronsly.     The  relative 


SPINE   AND    TRUNK.  29 

positions  of  the  shoulders,  scapulae  and  iliac  crests  can  be 
ascertained  by  sliding  the  horizontal  bar  into  the  desired 
position,  keeping  the  vertical  one  in  the  mid-line. 

There  can  be  little  doubt  we  shall  arrive  at  a  more  satis- 
factory conclusion  as  to  the  effect  of  treatment  on  cases  of 
scoliosis,  and  be  thereby  led  to  improved  methods  of  deal- 
ing with  this  malady,  by  the  use  of  some  reliable  recorder 
such  as  that  of  Mikulicz,  or  any  improvement  upon  it, 
and  I  make  no  excuse  for  drawing  the  attention  of  Ortho- 
paedic surgeons  to  its  value.  It  can  be  procured  of  Mr. 
Schramm,  64,  Belmont  Street,  Chalk  Farm  Road. 


30  BODILY   DEFORMITIES. 


S 


CHAPTER  IV. 


CURVATURES    OF   THE    SPINE. 


These  may  occur  in  a  lateral  or  antero-posterior  direction. 
The  former  are  much  the  commonest  in  adults,  and  will 
first  be  dealt  with. 

Definition.— Lateral  or  rotaro-lateral  curvature  of  the 
spine  or  scoliosis,  is  a  deviation  from  the  normal  shape  of 
the  spine  in  a  lateral  direction,  and  is  accompanied,  in 
almost  all  cases,  with  rotation  of  the  vertebral  segments. 

Synonyms. — German,  Ruckgratsverkrummung  oder 
Verbiegimg,  bogenformige  Defo?-mitat  der  Wirbelsaule,  Seit- 
liche  Verbiegung ;  French,  Scoliose. 

Frequency. — Scoliosis  is  the  most  common,  so  called, 
idiopathic  deviation  of  the  spine,  but  it  is  not,  as  some 
have  supposed,  really  more  common  than  spinal  caries.  If 
the  total  number  of  cases  of  spinal  flexure  and  disease  be 
considered,  general  experience  will,  I  feel  sure,  accord  with 
mine,  that  though  lateral  curvature  is  more  common  in 
adolescents  and  adults  than  in  children,  vertebral  caries  is 
far  more  common  in  children  than  in  adults,  so  that  after 
striking  a  balance  at  all  ages,  the  commonness  of  caries  in 
children  will  counterbalance  the  frequency  of  lateral  cur- 
vature in  adults. 

Varieties. — This  affection  may  be  congenital  or  acquired  ; 
the  former  being  rare  and  the  latter,  as  just  stated,  is 
common.     The  latter  may  also  be  idiopathic,  trau??iatic, 


CURVATURES    OF   THE    SPINE. 


31 


rachitic,  inflammatory,  or  statical,  and  it  may  be  due  to 
abnormalities  of  position  habitually  assumed  by  the 
patient,  which  lead  to  irregular  distribution  of  pressure  on 
the  spinal  column,  and  consequent  deformity.  Scoliosis 
may  be  primary  or  secondary.  In  the  first  instance  the 
mischief  originates  in  some  of  the  spinal  structures,  and  in 


Figs.  13  and  14.— Showing  the  production  of  lateral  curvature  by  inequality  in  the 
length  of  the  limbs,  and  the  result  of  rectifying  this. 

the  second  case  it  follows  irregularities  in  the  upper  limbs 
or  in  the  body-supports,  such  as  shortening  of  a  leg  from 
any  cause.  This  deformity  may  either  be  acute  or  rapid 
and  chronic,  or  slow  in  formation,  and  I  have  seen  cases  in 
which  a  pronounced  curve  developed  in  from  three  to  four 
months. 


32 


BODILY    DEFORMITIES. 


/ 


Causes. — Congenital  scoliosis,  of  which  I  have  seen  a  few 
well-marked  examples,  may  be  due  to  initial  debility  of  the 
vertebral  structures,  or  it  may  be  rachitic,  or  due  to  mal- 
formation of  the   bones,   or  to  a  bad  position  in  utero. 

Acquired  scoliosis  is  due,  like  most 
other  affections,  to  predisposing  and 


exciting 


or     determining    causes. 


Among  the  predisposing  causes,  age, 
sex,  and  heredity  are  important 
factors.  Females  are  much  more 
commonly  affected  than  males,  and 
this  greater  frequency  seems  to  be 
due  partly  to  the  greater  tendency 
to  laxity  of  the  ligamentous  and 
muscular  structures  in"  the  growing 
female,  and  partly  to  defective  habits 
of  standing  or  rather  lolling,  and 
partly  to  the  drain  on  the  constitu- 
tion which  menstruation  induces  in 
growing  girls.  The  age  at  which 
the  disease  is  most  commonly 
noticed  is,  in  my  experience,  from 
twelve  to  twenty-three  or  twenty- 
five,  though  it  may  occur  sooner  or 
later.  Of  course,  I  allude  to  the 
incipient  stage  of  the  disease,  for,  as 

Fig.    15. — Lateral   curvature,  -*  ° 

due    to    inequality  and    altered  is  Well  knOVVIl,     a     slight    deformity 

axis  of  support,  from  a  patient               b£  overlooked    and    only  come 

whose    leg   1   amputated    some  J  J 

years  before.  before   the  surgeon  at  a  compara- 

tively late  stage  when  the  malposi- 
tion is  more  or  less  fixed.  As  regards  heredity,  there  can  be 
no  question  but  that  the  tendency  to  the  disease  is  propa- 
gated from  .parent  to  offspring  ;  and  I  have  seen,  as  before 
observed,  congenital  cases  in  which  one  parent  only  was 


CURVATURES    OF    THE    SPINE. 


33 


similarly  affected  ;  others  in  which  several  on  one,  or  both 
sides  of  the  parents'  family  suffered  from  a  similar  affection, 
and  yet  others  in  which  there  was  neither  history  nor  evi- 
dence of  scoliosis  in  either  of  the  parents,  nor  in  any  of  the 
relatives.  A  feeble  constitution  is  an  important  predispos- 
ing factor,  whether  congenital  or  acquired.     If  the  former, 


Fig.  16. — Lateral  curvature,  due  to  unequal  weight  on  the  two  sides  of  the  trunk, 
from  a  patient  whose  right  arm  1  amputated  at  the  shoulder  for  a  machinery 
accident.     The  curve  is  towards  the  heavier  side. 

this  cause  would  come  under  the  head  of  heredity,  though 
sometimes  feeble  offspring  come  from  vigorous  parents. 

Among  the  exciting  causes,  bad  positions,  which  children 
often  assume  at  their  studies  in  sitting  or  standing,  are  pro- 
bably the  most  frequent;  but  in  adolescents,  and  especially 
among  the  lower  classes,  the  irregular  pressure  of  weight- 


34  BODILY   DEFORMITIES. 

bearing,  or  carrying,  is  a  strong  determinant  of  the  disorder. 
The  writing-desks  at  many  schools,  even  now-a-days,  are  so 
badly  constructed,  and  placed  so  low,  that  the  children 
have  to  incline  their  spines,  and  the  repetition  of  this  evil 
position,  though  for  a  comparatively  short  time  every  day, 
will  produce  in  time  a  deviation,  and  unless  this  deviation 
be  observed  early,  and  its  cause  removed,  the  curvature  will 
become  aggravated  and  even  permanent.  Young  nurse- 
maids there  are,  who  carry  children  always  upon  the  same 
arm,  and  have  to  incline  the  trunk  in  the  opposite  direction 
to  establish  equilibrium,  and  thus  they  induce  lateral  devia- 
tion. 

All  causes,  in  fact,  which  induce  a  lateral  inclination  of 
the  body,  may  produce  scoliosis,  whether  they  be  weight- 
bearing  or  carrying,  irregularity  in  the  length  of  the  limbs, 
or  in  the  mode  of  standing ;  or  whether  the  inclination  be 
due  to  paralysis  or  contraction  of  the  spinal  muscles. 

There  is  another  important  cause  arising  within  the  body 
which  produces  some  of  the  worst  forms  of  lateral  curvature. 
I  mean  those  due  to  pleurisy  of  one  side,  with  collapse  of  the 
lung,  and  the  presence  of  firm  adhesions.  This  form,  unless 
taken  very  early,  is  not  amenable  to  any  improvement. 
Severe  burns  of  the  thorax,  resulting  in  large  and  dense 
cicatricial  bands,  may  also  produce  lateral  deviation.  I 
must  also  draw  attention  to  the  fact  that  irregularity  of  posi- 
tion at  the  upper  end  of  the  spinal  column,  as  in  torticollis, 
or  in  bearing  weights  upon  the  head,  may  also  produce 
lateral  curvature ;  as  may  also  inequalities  of  weight  of  the 
lateral  portions  of  the  body,  such  as  the  loss  of  an  upper 
or  lower  limb  ;  and  I  have  often  observed  a  secondary 
deviation  in  those  who  have  worn  an  artificial  leg,  or  a 
bucket  and  stump,  for  a  year  or  more,  and  sometimes  it 
occurs  even  in  a  shorter  period. 

Pathogenesis.— Various  theories  have  been  proposed  to 


CURVATURES    OF    THE    SPINE. 


35 


explain  how  the  different  possible  causes  act  in  producing 
scoliosis.  Some  writers  attribute  it  entirely  to  irregularity 
in  muscular  action,  others  blame  the  ligaments,  and  others 
the  bones.  Mayo  thought  that  there  was  a  defective 
growth  in  the  muscles.  Gue'rin  thought  that  muscular 
retraction  was  the  cause,  and  the  German  school,  until 
recently,   attributed  it  to   muscular   relaxation ;    but   ana- 


Fig.  17. — Left  Pleuritic  lateral  curvature  in  a  boy.     Anterior  view  to  show  collapse 

of  the  chest-wall. 


tomical,  physiological,  and  pathological  .  observations 
clearly  show  that  these  views  are  too  exclusive.  The 
same  may  be  said  of  the  view  of  Delpech,  who  attri- 
buted it  to  an  engorgement  of  the  inter-vertebral  fibro- 
cartilages.  I  am  now  speaking  of  primary  scoliosis,  as 
those  cases  which  are  secondary,  are  clearly  due  to  certain 
static   and  mechanical   conditions  which    I    will    explain 

d  2 


3^ 


BODILY    DEFORMITIES. 


presently.  There  is  yet  another  set  of  rare  cases  which,  so 
far  as  we  at  present  know,  are  occasionally  and  undoubtedly 
due  to  a  primary  malformation,  or  ill-development,  or 
absence  of  some  of  the  vertebral  segments,  or  parts  of 
them  and  their  articulations ;  and  I  am  also  convinced  that 
not  a  few  cases  can  be  satisfactorily  explained  by  altered 
growth,  or  ossification  in  the  affected  portion  of  the  spine, 


Fig.  18.— Left  Pleuritic  lateral  curvature.     Posterior  view. 

and  I  have  seen  such  cases  to  which  no  other. explanation 
would  fit. 

Malgaigne  thought  that  lateral  curvature  was  due  to  a 
relaxation  of  the  peripheral  ligaments  of  the  spine,  and  that 
a  feeble  muscular  system  left  to  the  ligamentous  apparatus 
almost  the  entire  task  of  sustaining  the  column,  and  these 
ligaments    becoming    incapable,    the     spine    assumed    a 


CURVATURES    OF   THE    SPINE.  37 

curvature  in  accord  with  the  position  habitual  to  the 
body  of  the  patient.  The  ligaments  on  the  concave  side 
become  contracted,  and  maintain  the  deformity,  whereas 
those  on  the  opposite  side  become  stretched  and  relaxed. 
On  the  concave  side,  the  contracted  ligaments  produce 
pressure  on  the  vertebral  bodies  and  inter-vertebral  seg- 
ments, and  produce  in  them  consecutive  absorption  and 
alteration  in  form. 

The  Osseous  Theories  are  three.  Bouvier  maintained 
that  scoliosis  was  due  to  a  defect  in  the  plasticity  of  the 
bones,  which  rendered  them  more  susceptible  to  yield 
under  the  influence  of  certain  causes  which  are  believed, 
or  known,  to  aid  in  the  production  of  the  spinal  curves, 
such  as  the  beating  of  the  aorta,  the  greater  weight  and 
exercise  of  the  right  or  left  limb,  whichever  happens  to 
be  the  most  used.  Hiieter  thought  that  this  affection  was 
consecutive  to  deformity  of  the  ribs,  and  that  these  by 
their  leverage  produce  rotaro-lateral  distortion ;  but  it  is 
far  more  common  for  the  ribs  to  become  secondarily 
involved  through  a  primarily  spinal  deviation.  The  third 
is  the  statical  theory,  which  attributes  the  alteration  in  the 
bones  to  abnormal  position  of  body-weight  pressure,  and 
regards  the  changes  in  the  muscles,  &c,  as  secondary  to 
this. 

There  are  other  theories  into  which  I  need  not  enter ; 
and  though  it  must  necessarily  be  some  time  before  we  get 
enough  pathological  material  to  definitely  solve  these 
important  questions,  I  would  state  my  conviction,  from 
what  I  have  observed  in  the  living,  and  from  the  few  post- 
mortems which  I  have  been  enabled  to  make,  or  see  made 
satisfactorily,  that  in  the  stage  in  which  pathological 
anatomy  can  speak  from  experience,  we  find  all  the  struc- 
tures more  or  less  involved,  muscles  degenerated,  bones 
deformed,  inter-vertebral  discs  compressed,  ligaments  con- 


38  BODILY    DEFORMITIES. 

tracted  on  the  one  side,  and  lengthened  and  degenerated 
on  the  other,  and  the  joint  surfaces  altered.     I  have  never 
seen  an  autopsy  made  in  an  incipient  stage  of  the  disease, 
and  even  if  I  knew  that  such  an  opportunity  would  present 
itself  to  me  at  once,  I  should  not  be  at  all   sanguine  of 
finding  the  vera  causa  of  the   disease,  but  should  rather 
expect  to  find  certain  changes  of  shape,  in  an  early  stage, 
the  causes  of  which  would   still  remain   doubtful.     If,  in 
the   living,    and  even  post-mortem,   there    existed  marked 
deformity,  and  if  there  were  no  sufficient  bony  deformity 
to  account  for  it,  such  a  condition  would  naturally  support 
the  muscular  and  ligamentous  theories  ;  but  if  there  were 
present  marked  bony   deformity  without  any  noteworthy 
changes  in  the  muscular  and  ligamentous  systems,  which 
could  not  be  correctly  considered  consecutive  to  the  bony 
deformity,  then  the  osseous  theory  would  find  some  sub- 
stantial   support.       I    must   now   leave   this   part   of   the 
question,  and  content  myself  with  stating  my  belief  that  in 
many  cases  the  causes  are  manifold  rather  than  single  and 
simple ;  but  I  may  just  enumerate  the  various  views  which 
have  from  time  to  time  been  held,  leaving  their  discussion 
for  publication  in  another  place. 

Various  views  on  (Etiology. — The  conflicting  views  which 
have  been  held  at  various  times  as  to  the  cause  of  so-called 
idiopathic  scoliosis  are  that  it  is  due  to — 1.  Traumatisms, 
luxations,  &c. ;  2.  To  congenital  malformation  of  the  spinal 
column ;  3.  To  irregular  distribution  of  weight  on  the  two 
sides  of  the  body,  both  as  regards  the  viscera  and  the 
greater  weight  of  the  right  arm ;  4.  To  the  pushing  of  the 
spinal  column  to  the  left  through  the  aortic  pulsations;  5. 
To  paralysis  of  some  of  the  spinal  muscles  or  of  the  ser- 
ratus  magnus  ;  6.  To  debility  and  relaxation  of  muscles 
and  ligaments ;  7.  To  disturbance  of  the  equilibrium  of 
the  muscles  on  either  side  of  the  spine  (the  antagonist 


CURVATURES    OF   THE    SPINE.  39 

theory) ;  8.  To  primary  abnormal  bony  growth  of  the  ribs ; 
9.  To  fixation  of  a  defective  habitual  or  constantly  repeated 
attitude;  10.  To  unequal,  i.e.  unilateral,  pressure  through 
weight-bearing  on  the  head,  shoulders,  or  arms;  11.  To 
engorgement  of  the  inter-vertebral  fibro-cartilages  ;  12. 
Nicoladoni's  recent  theory,  which  regards  ■  torsion  as  appa- 
rent and  due  to  a  general  optical  impression  caused  by  the 
high  degree  of  asymmetry  of  the  individual  vertebra;*  13. 
To  general,  constitutional,  or  diathetic  causes  ;  14.  To 
vertebral  articular  disease;  15.  To  arrested  or  altered 
growth  in  the  vertebrae.  The  last  two  are  my  explanations 
of  some  cases  which  have  not  been  amenable  to  other 
hypotheses,  and  the  articular  cases  furnished  symptoms, 
such  as  localized  pain  on  pressure  and  motion,  and,  in  one 
case,  abscess  communicating  with  the  costo-vertebral  joint, 
which  to  me  seemed  sufficient  evidence  of  the  pathogenesis 
of  the  cases. 

Diagnosis.— This  comprehends  three  points  :  d)  to 
ascertain  that  lateral  curvature  really  exists  ;  (2)  to  deter- 
mine its  nature ;  and  (3)  to  differentiate  it  from  other 
diseases  and  deformities  of  this  region.  The  means  at 
our  disposal  are  inspection,  palpation,  and  certain  instru- 
mental aids  already  described.  Of  course  when  lateral 
curvature  has  arrived  at  a  well-marked  stage,  it  is  easy 
to  recognize  it,  but  when  the  malady  is  incipient  it  is 
not  such  a  simple  matter.  For  instance,  in  cases  in 
which  the  spinous  processes  retain  their  normal  position, 
one  has  merely  a  prominence  of  one  side  of  the  back 
or  loins,  to  indicate  any  deviation ;  and  this  sign,  of 
itself,  is  not  a  certain  indication  of  the  presence  of  lateral 
curvature-;  but  if  it  be  accompanied  by  a  projection  of  the 
opposite  side,  above  or  below  it,  this  would  show  that 
deviation  of  the  column  had  taken  place.  Even  projection 
*  Die  Torsion  der  Skoliotischen  Wirbelsaule,  d^c,  1882. 


4° 


BODILY   DEFORMITIES. 


of  the  anterior  or  lateral  thoracic  parietes,  only  indicates 
scoliosis  when  there  is  a  corresponding  projection  on  the 
back  part  of  the  opposite  side  of  the  chest ;  but  it  should 
be  mentioned  that  not  infrequently  there  is  a  depression 
instead  of  a  projection  on  the  opposite  side.  If  there  be 
a  deviation  of  the  spinous  processes  the  diagnosis  is  usually 
easy. 

In  cases  in  which  there  exists  but  one'  curvature,  or  in 


Fig.  19. — Defective  development  of  left  scapula,  which  is  much  smaller  and  on 
a  much  higher  level  than  the  right.     Also  slight  lateral  secondary  curvature. 

those  in  which  the  secondary  curve  has  not  yet  had  time 
to  form,  the  diagnosis  between  rotaro-lateral  curvature  and 
a  simple  flexion,  is  not  obvious,  but  it  may  help  us  to 
recollect,  not  only  that  simple  flexion  is  not  common,  but 
that  when  it  exists,  it  occurs  most  frequently  in  the  more 
movable  portions  of  the  spine  (the  cervical  portion 
excepted) ;  that  is  to  say,  in  the  lower  part  of  the  dorsal, 
and  upper  part  of  the  lumbar  regions,  and  that  the  curve 


CURVATURES    OF   THE    SPINE.  4 1 

of  a  flexion  has  a  greater  radius  than  that  of  a  scoliosis. 
In  severe  cases  of  flexion,  the  skin  and  subcutaneous 
tissues  are  thrown  into  folds  on  the  concave  side,,  whereas 
in  scoliosis  there  is  usually  a  deepish  groove,  rarely  more, 
on  this  side.  It  is  uncommon  for  skin  folds  to  exist  in 
scoliosis,  except  in  extreme  cases,  or  in  the  later  stages  of 
the  malady.  These  folds  and  grooves  may.  be  to  some 
extent  obliterated,  by  making  the  patient  lie  down,  or  by 
extension  of  the  spine  through  suspension  of  the  body  by 
the  occiput  and  chin,  or  by  the  arm-pits. 

When  the  curvature  is  double,  i.e.,  when  the  secondary 
curve  has  formed,  diagnosis  is  simplified.  It  is  very  rare 
indeed  for  a  simultaneous  double  curvature  to  occur,  and 
if  there  be  three  curves  the  diagnosis  is  easy,  for  the 
contracted  muscles  form  projections  which  aid  us,  and  the 
deviations  of  the  pelvis,  of  the  head,  and  of  the  shoulder- 
blades  confirm  the  diagnosis.  When  rotation,  i.e.,  torsion 
of  the  vertebrae  co-exists,  there  will  be  present,  with  the 
dorsal  and  thoracic  projections,  a  deviation  of  the  spinous 
and  transverse  processes  and  ribs,  and  all  doubt  will  then 
be  removed. 

Sometimes  with  vertebral  caries  there  exists  a  lateral 
curvature,  but  the  history  will  guide  us  in  these  rare  cases. 
In  some  cases  it  will  be  found  that  the  scoliosis  has  pre- 
existed and  been  followed  by  caries,  and  in  others  that  the 
carious  vertebrae  have  subsided  laterally,  and  when  anchy- 
losed,  have  formed  a  lateral  curve  at  the  site  of  the  disease, 
or  there  may  be  a  secondary  lateral  curve  above  or  below 
the  cyphotic  projection.  In  these  cases  the  lateral  curvature 
is  secondary,  and  in  yet  others,  the  cyphotic  and  scoliotic 
processes,  appear  to  have  come  on  together,  but  the  lateral 
curvature  progresses  rapidly,  and  as  a  rule,  its  arc  is  less 
than  that  of  an  ordinary  scoliosis. 

The  hysterical  and  malingering  spine  may  be  mistaken 


42 


BODILY   DEFORMITIES. 


for  true  lateral  curvature ;  but  the  absence  of  secondary 
deformity  and  the  presence  of  suspicious  elements  in  the 
case,  together  with  the  use  of  anaesthetics,  as  well  as  the 
result  of  proper  treatment,  will  aid  us  in  coming  to  a 
correct  conclusion.  Drop-shoulder,  i.e.  the  condition  in 
which  one  shoulder  is  on  a  much  lower  level  than  the  other, 
is  not  uncommonly  met  with  in  hysterical  girls. 

It  will  not  be  enough  for  us,  as  conscientious  surgeons,  to 
be  satisfied  with  the  simple  diagnosis,  but  we  must  endea- 
vour to  ascertain  the  cause  of  the  malady ;  that  is  to  say,  to 


Fig.  20. — Congenital  scoliosis  in  girl  set  3.     No  rickets. 

form  an  aetiological  diagnosis,  and  to  ascertain  whether  the 
malady  be  symptomatic,  or  idiopathic  and  essential.  I 
leave  out  of  the  present  question  the  congenital  and 
rachitic  forms,  for  these  obviously  occur  at  much  earlier 
ages,  and  in  the  latter,  there  are  other  evidences  of  rickets 
to  guide  us.  If  the  curvature  be  symptomatic  of  a 
pleurisy,  the  collapsed  state  of  the  thorax  on  that  side, 
combined  with  auscultation,  percussion,  and  the  previous 
history,  will  settle  the  matter.     If  the  disease  be  statical, 


CURVATURES    OF   THE    SPINE.  43 

i.e.,  due  to  mechanical  causes,  such  as  loss  of  a  limb  or 
inequality  in  the  length  of  the  legs,  or  to  weight-bearing,  the 
greater  curve  will  be  near  the  part  causing  it ;  for  instance, 
if  an  arm  have  been  lost  at  the  shoulder,  the  curvature 
will  be  in  the  upper  dorsal  region  on  the  opposite  side,  and 
if  it  be  due  to  inequality  in  the  length  of  the  legs,  the 
dominating  curve  is  placed  in  the  loins.  Other  diagnostic 
signs  are  given  in  the  next  paragraph. 

Symptoms.— Though  curious,  it  is  however  true,  that 
this  affection,  which  should  be  obvious  to  the  eye,  is  rarely 
noticed  at  a  very  early  stage,  and  even  in  those  cases 
where  pain  in  the  back  is  complained  of,  it  is  attributed  to 
something  else.  The  first  symptom  which  generally 
attracts  the  notice  of  the  parents,  or  of  the  patient,  is  a 
growing  out  of  the  shoulder  blade.  I  have  seen  several 
cases  of  marked  deformity  which  have  passed  unnoticed, 
though  the  parents  have  been  in  the  habit  of  frequently 
seeing  their  children  in  a  nude  condition. 

The  subjective  symptoms  are  not  usually  strongly  marked, 
but  when  present  pain  is  the  chief  one,  and  is  of  a  varying 
character,  and  commonly  in  the  back  and  sides  near  the  part 
affected  ;  and  there  is  a  feeling  of  lassitude,  as  if  the  back 
required  support,  and  the  patients  express  themselves  much 
relieved  by  sitting  or  lying.  The  objective  signs  are  promi- 
nence of  a  shoulder-blade,  generally  the  right,  forming  what 
is  known  to  the  public  as  "  a  shoulder  growing  out."  On 
examination,  it  will  be  found  that  when  this  condition  exists 
the  curvature  has  become  well  marked,  and  this  inequality  of 
position  of  the  scapulae  is  due  not  only  to  the  lateral  spinal 
deviation,  but  also  to  the  posterior  projection  of  the  ribs 
on  the  convex  side  of  the  curvature,  so  that  the  scapula  is 
pushed  out  and  back  by  the  projection  of  the  ribs.  In 
mild  forms  of  simple  flexion  or  inclination  of  the  spine, 
there  is  a  difference  in  the  position  of  the  scapulae,  but  it 


44  BODILY    DEFORMITIES. 

is  of  a  different  character,  being  less  pronounced  and  not 
giving  the  appearance  that  one  shoulder-blade  is  larger 
than  the  other. 

This  sign  of  shoulder  projection  may  occur  in  all  dorsal 
deviations,  whether  primary  or  secondary,  and  will  indicate 
the  convex  side  of  the  curvature,  that  is  to  say,  if  the  right 
shoulder  project,  the  dorsal  curve  is  to  the  right,  and 
vice  versa  ;  and  if  the  lumbar  curvature,  secondary  to  the 
dorsal,  have  formed,  its  convexity  will  be  on  the  opposite 
side  to  that  of  the  primary  curve.  In  cases  where  the 
initial  or  primary  curve  is  lumbar,  and  the  secondary  or 
compensatory  curve  is  dorsal,  the  scapulae  may  be  on  the 
same  level,  especially  if  the  two  curvatures  have  the  same 
arc.  In  the  lumbar  region  and  at  the  hips,  an  opposite 
condition  will  be  observed  ;  for  instance,  in  a  right  dorsal 
curvature,  the  hip  on  the  left  or  concave  side  of  the  curve 
will  appear  more  projecting,  that  on  the  right  side  being 
flattened  or  depressed,  though  there  is  really  no  difference 
in  position  between  the  innominate  bones  in  ordinary  cases. 
In  cases  where  there  is  pelvic  obliquity,  whether  primary 
or  secondary,  measurement  will  demonstrate  that  the 
anterior  superior  spines  are  on  a  different  level,  not  only  as 
regards  height,  but  also  in  an  antero-posterior  direction  ; 
that  is  to  say,  torsion  may  be  combined  with  obliquity  of 
the  pelvis.  The  reason  for  this  apparent  projection  of  the 
hip  on  the  concave  or  opposite  side  to  the  curvature,  is 
the  depression  which  exists  above  it,  obliterating  the  flank 
or  loin,  whilst  on  the  convex  side  the  line  connecting  the 
loin,  hip  and  buttock  is  normal,  though  the  parts  just  above 
the  posterior  part  of  the  innominate  bone  on  this  side, 
especially  the  erector  spinse,  are  sometimes  more  prominent, 
forming  a  contrast  to  the  groove  or  hollow  on  the  opposite 
side. 

Carrying  the  examination  further,  one  will  find  that  the 


CURVATURES    OF    THE    SPINE.  45 

spinous  processes  have  deviated  from  the  normal  mid-line, 
and  in  the  case  of  a  right  dorsal  curvature,  the  convexity 
of  these  will  be  to  the  right,  and  it  will  generally  be  found 
that  cases  of  lateral  curvature  are  exaggerations  and  exten- 
sions of  the  normal  spinal  curves.  Secondary  or  com- 
pensatory curvatures,  whether  occurring  in  the  lower  or 
lumbar  part,  or  in  the  upper  or  cervical-dorsal  region,  are 
always  on  the  opposite  side  to  the  primary  curve.  The 
ribs  on  the  side  of  the  curvature  are  pushed  back  so  that 
the  shoulder-blade  is  forced  out  and  its  angle  projects, 
whereas  on  the  opposite  or  concave  side,  the  scapula 
appears  more  or  less  flattened,  and  is  more  readily  moved 
by  the  surgeon.  Occasionally  the  inferior  angle  of  the 
scapula  on  the  convex  side  is  not  prominent,  as  is  the  rule, 
whereas  on  the  opposite  side  it  projects.  In  the  first  in- 
stance, this  will  depend  upon  the  degree  of  the  deformity 
of  the  ribs,  the  number  of  them  displaced,  and  the  position 
of  this  displacement.  In  the  latter  the  projection  of  the 
scapula  appears  to  be  compensatory,  and  due  to  muscular 
action. 

In  extreme  cases,  or  cases  of  long  standing,  the  curves 
become  increased  and  exaggerated  until  the  patient  has 
ceased  growing,  and  even,  in  some  cases,  for  some  time 
after ;  and  this  is  the  case  with  the  secondary  as  well  as 
the  primary  curve,  and  so  deformed  does  the  spine  become, 
that  in  some  instances  it  requires  care  to  differentiate  it 
from  a  severe  case  of  Pott's  disease,  as  not  only  is  there 
a  very  great  posterior  projection,  but  there  is  also  formed 
an  anterior  one,  usually  on  the  opposite  side — that  is  to 
say,  on  the  left  antero-lateral  side  of  the  thorax  if  the  cur- 
vature be  right  dorsal.  This  anterior  projection  of  the  ribs 
and  sternum — if  the  latter  be  affected — is  less  pronounced 
than  the  dorsal  deformity,  and  it  may,  by  the  inexperienced, 
be  confounded  with  rhachitic  thoracic  deformity,  or  even 


46  BODILY   DEFORMITIES. 

with  the  chest  deviation  occurring  in  vertebral  caries.  In 
very  bad  cases  the  hollow  in  the  flank  beneath  the  projec- 
tion is  very  narrow  and  deep,  and  I  have  seen  cases  in 
which  the  lower  ribs  not  only  touched,  but  over-rode  the 
corresponding  innominate  bone,  so  that  the  fingers  could 
not  be  passed  between  them.  Sometimes  this  causes  very 
great  pain  and  inconvenience,   which  is  very  difficult  to 


Fig.  21.     Left  dorso-lumbar  curvature,  showing  the  falling-in  and  creasing  of  the 
right  ilio-costal  region,  and  the  altered  level  of  the  scapulae,  shoulders,  and  hips. 

alleviate.  I  may  draw  attention  to  a  circumstance  over- 
looked in  all  works  on  the  subject — viz.,  to  the  existence 
of  subcutaneous  bursse  beneath  these  points  of  projection, 
and  I  have  known  these  become  very  tender,  and  even  to 
inflame  and  suppurate. 

Many  sufferers  from  severe  lateral  curvature  carry  them- 
selves in  a  peculiar  manner,  appreciable  to  the  experienced 
eye.     They  have  what  may  be  termed  a  hippy  walk — that 


CURVATURES    OF   THE    SPINE.  47 

is  to  say,  one  hip  is  much  more  prominent  than  the  other, 
and  even  in  sitting,  this  prominence  is  noticeable.  This  is 
due  to  pelvic  obliquity,  it  being  inclined  towards  the 
the  convex  side  of  the  curvature,  the  corresponding  lower 
limb  being  slightly  flexed,  and  carried  forward.  The  patients 
generally  carry  themselves  so  that  the  body  is  inclined  to 
the  side  away  from  the  deformity. 

I  may  remark,  in  passing,  on  other  supposed  popular  signs 
belonging  to  sufferers  from  spinal  disease  ;  these  are  bad 
and  revengeful  temper,  great  intelligence,  and  intense  vene- 
real capabilities ;  but  I  need  scarcely  state  that  such  cases 
are  exceptions  rather  than  the  rule.  It  is  true  that  some 
sufferers  from  lateral  curvature  are  bad-tempered,  and 
no  wonder ;  it  is  equally  true  that  some  are  very  intelli- 
gent, but  I  have  found  that  sufferers  from  spinal  caries 
commonly  possess  higher  intelligence  than  those  from 
lateral  curvature,  and  I  think  this  is  to  be  partly  explained 
from  the  well-known  fact  that  tubercular  people  are  often 
of  very  active  mental  habits,  and  partly  by  the  fact  of  their 
illness  and  isolation  throwing  them  more  on  their  own 
resources,  and  inclining  them  to  compensate  for  their 
physical  deficiency  by  mental  superiority.  As  for  the  last 
allegation,  I  can  only  suppose  that  to  be  true  in  cases 
where  there  is  a  chronic  irritation  in  the  lumbar  portion  of 
the  cord.  I  cannot  say,  from  actual  personal  experience, 
whether  there  is  any  truth  in  the  statement  as  regards 
sufferers  from  lateral  curvature. 

The  bony  deformities  are  followed  by  changes  in  the 
soft  parts  and  viscera  which  may  aid  in  the  diagnosis,  and 
must  be  well  taken  into  consideration  in  our  treatment. 
In  advanced  scoliosis  the  head  and  neck  are  often  drawn 
forwards,  or  to  one  side.  This  inclination  is  towards  the 
concave  side  of  the  dorsal  curvature  if  this  be  high,  but 
sometimes  they  are  inclined  to  the  opposite  side  if  the 


48 


BODILY    DEFORMITIES. 


curve  be  very  pronounced.  The  head  generally  follows  the 
direction  of  the  inclination  of  the  neck,  but  sometimes  it 
deviates  to  the  opposite  side.  The  abdo??ien  projects  in 
front,  and  appears  shortened,  and  often  limited  by  a  groove 
at  its  upper  and  lower  parts.  The  loins  are  convex  on  the 
convex  side,  and  concave  on  the  opposite,  and  the  distance 
between  them  and  the  hips  is  shortened,  especially  on  the 
convex  side,  in   consequence  of   the   ribs    being    pushed 


Fig.  22.— To  show  the  deviation  of  the  anterior   mid-line  of  the  body,  and  the 
altered  position  of  the  breasts  in  lateral  curvature. 

towards  the  os  nominatum.  The  hips,  as  already  stated* 
appear  unequal,  that  on  the  convex  side  appearing  flattened, 
and  that  on  the  concave  being  more  prominent.  There  is 
also',  in  well-marked  cases,  a  difference  in  the  position  of 
the  breasts,  the  mammae. on  the  side  of  the  anterolateral 
thoracic  deformity  being  thrown  more  forward,  and  some- 
what displaced  outwards  and  downwards,  the  mid-line  is 
also  deviated  to  the  affected  side. 


CURVATURES    OF   THE    SPINE.  49 

Following  the  initial    symptoms  are   languor,   ancemia, 
general  lassitude,   and  local  pains,  and,  in  proportion  as 
the  disease  becomes  more  advanced,  symptoms  showing 
involvement  of  the  thoracic  and  abdominal  viscera,  or  of 
the  nerves  and  muscular  system,  become  apparent.     There 
is  more  or  less  blood  stasis  in  the  venous  system  and  right 
side  of  the  heart,  then  dilatation  of  this  side  of  the  organ, 
palpitation,  faintings,  and  sometimes  nasal,  gastric  or  rectal 
haemorrhage.     In  females  there  is  often  an  irregularity  of 
menstruation  and  uterine  displacement  accompanying  the 
pelvic  deformity.     Pain  in  the  back,  as  women  call  it — 
that  is,  about  the  lumbar  portion  of  the  spine — is  often  due 
to  uterine  or  rectal  mischief,  and  must  always  be  present 
in  our  consideration  so  as  to  differentiate  these  causes  of 
pain  from  those  due  to  lumbar  caries  or  lumbar  scoliosis  \ 
and  one  must  also  recollect  that  myelitis,  meningitis,  or 
tumours   of  this  region  of  the  cord  may  also  cause  pain, 
which   is,   however,   of  a  much   more    acute  and    severe 
character.     But  when  these  latter  diseases  cause  pain,  they 
also  give  rise  to  other  temporary  or  permanent  symptoms 
such    as  tingling,  twitching,   or    paralysis,   which  will  aid 
materially  in  the  diagnosis.     The  importance  of  having  a 
large   experience  and  knowledge  of   all  branches  of  our 
profession  before  any  one  has  a  right  to  consider  himself 
either  a  competent  general,  or  special  practitioner  is,  in 
such  obscure  cases,  well  exemplified.     General  knowledge, 
if  sufficiently  deep,  cannot  but  make  one  a  better  specialist; 
whereas,  however  deep  one's   special  knowledge  may  be, 
this  of  itself  will  only  render  one  more  unfit  to  be  a  good 
general  practitioner. 

It  is  almost  always  observed  that  patients  with  well- 
marked  lateral  curvature  and  thoracic  deformity  are  very 
short-winded.  They  cannot  go  upstairs  quickly,  neither 
can  they  walk  briskly,  nor  run,  the  vital  capacity  of  their 

E 


^0  BODILY    DEFORMITIES. 

lungs  is  diminished.  This  is  partly  due  to  the  deficient 
mobility  of  the  thoracic  parietes,  and  partly  to  the 
diminished  capacity  of  the  lungs  following  the  altered 
shape  of  the  thorax.  These  changes  in  the  lungs  neces- 
sarily lead  to  secondary  affections  of  the  heart,  such  as  I 
have  just  described,  and  these  again  re-act  upon  the  lungs 
and  also  upon  the  abdominal  viscera.  In  consequence  of 
these  changes  in  the  heart  and  lungs,  these  patients  are 
subject  to  bronchitis,  congestion,  and  pneumonia,  and  they 
should  be  specially  warned  against  sudden  exercise,  or 
extremes  of  temperature.  It  is  very  rare  for  these  people 
to  be  good  singers  or  public  speakers,  because  of  the 
physiological  inactivity  of  their  thoracic  viscera,  and  not 
a  few  of  them  end  in  acquiring  phthisis.  Auscultation  at 
the  point  where  the  thorax  is  bossed  or  gibbous,  will  elicit 
that  the  respiratory  murmur  is  very  feeble  or  even  abolished, 
whereas  over  the  rest  of  the  chest  it  is  increased,  and  even 
of  a  bronchial  character,  and  percussion  will  elicit  dulness 
on  this  side  of  the  cavity,  showing  that  the  air-cells  of  this 
portion  of  the  lungs  are  more  or  less  effaced,  and  some- 
times this  dulness  is  due  to  pulmonary  congestion,  caused 
as  has  been  already  explained.  In  later  stages  these  sub- 
jects become  emphysematous,  and  are  subject  to  the  train 
of  symptoms  accompanying  this  condition  of  the  lungs. 

In  severe  cases  the  adjacent  organs  become  involved, 
the  liver  is  pressed  upon,  its  action  more  or  less  interfered 
with,  and,  as  a  consequence,  constipation  is  not  a  very  un- 
common concomitant  of  bad  scoliosis.  Indigestion  is  far 
more  common,  but,  independently  of  this,  these  people 
are  rarely  large  eaters,  partly  because  of  the  compression 
to  which  their  abdominal  viscerae  are  subjected,  and  partly 
in  consequence  of  their  inability  to  take  sufficient  exercise 
to  create  a  large  demand  for  food. 

As  regards  the  nervous  system,  it  is  very  rare  to  observe 


CURVATURES   OF   THE    SPINE. 


5* 


anything  serious,  such  as  loss  of  motion  or  sensation 
through  compression  of  the  spinal  cord,  or  of  the  nerves 
leaving  it,  but  neuralgia  is,  however,  common,  and  follows 
the  course  of  the  nerves  issuing  from  the  vertebrae 
affected. 

The  muscular  system  is   enfeebled,  the   patients  being 


Fig.  23. — Right  lower  dorsal  and  left  lumbar  curvatures,  showing  unequal  height 
of  shoulders  and  foldings  of  the  soft  parts  in  the  left  ilio-costal  region.  The  left  hip 
is  higher  than  the  right. 

unwell  or  unable  to  take  exercise.  The  muscles  which 
suffer  most  are  the  spinal,  many  of  which  become,  after 
a  time,  fattily  degenerated. 

Pathological  Anatomy. — At  present,  although  there 
is  enough  material  to  guide  us  in  coming  to  proximate 
conclusions  as  to  the  changes  in  the  bony  and  ligamentous 

e  2 


52  BODILY   DEFORMITIES. 

structures,  still  the  history  of  the  changes  in  their  entirety 
have  yet  to  be  worked  out,  and  it  will  only  be  when  a  suffi- 
cient number  of  careful  examinations  of  the  various  forms 
of  lateral  curvature  in  the  incipient  stages  have  been  made, 
that  the  true  pathology  of  this  affection  can  be  elucidated. 
I  have  only  seen  or  made  post-mortems  in  three  cases  of 
the  ordinary,  or  so-called  idiopathic  form  of  lateral  curva- 
ture, and  in  one  of  these  the  disease  was  in  a  rather  early 
condition.  The  results  of  these  examinations,  with  the 
observations  of  other  workers,  must  form  the  basis  of  the 
following  remarks. 

Bones. — The  bodies  of  the  vertebrae,  and  the  intervertebral 
discs  are  diminished  in  height,  i.e.,  compressed  on  the  con- 
cave side  of  the  deformity,  and  the  amount  of  this  decrease 
will  vary  with  the  amount  of  deformity.  There  is  also  a 
groove  on  the  side  of  the  vertebrae  along  the  concavity.  On 
transverse  section  the  affected  bodies  and  intervertebral 
substances  have  a  wedge-shaped  appearance,  and  if,  before 
section,  the  vertebrae  be  separated  from  each  other  their 
upper  and  lower  surfaces  will  be  seen  to  be  altered,  being 
larger  on  the  convex  and  contracted  on  the  opposite  side. 
In  severe  cases  some  of  the  intervertebral  discs  and  adjoin- 
ing vertebral  segments  have  become  absorbed  on  the  side 
of  pressure,  and  anchylosed.  Delpech  has  described  a 
lozenge-shaped  depression  due  to  rotation  and  torsion  on 
an  antero-posterior  axis,  so  that  a  vertical  transverse  section 
of  such  vertebrae  would,  on  account  of  the  turning  of  the 
upper  or  lower  surface  towards  the  right  or  left,  present  the 
appearance  of  an  oblique-angled  parallelogram.  In  a 
similar  section  of  the  normal  spine  the  geometrical  figure 
is  that  of  a  right-angled  parallelogram. 

If  the  disease,  commencing,  as  it  usually  does,  at  the  age 
of  puberty,  be  severe  or  have  progressed  rapidly,  the  process 
of  ossification  is  interfered  with  on  the  side  of  pressure 


CURVATURES    OF    THE    SPINE. 


53 


but  on  the  opposite  side,  excess  of  growth  occurs.  In  such 
cases  anatomical  examination  reveals  veil-marked  changes 
in  the  other  constituents  of  the  vertebrae. 

The  articular  processes  are  contracted,  though  elon- 
gated from  above  downwards  on  the  convex  side, 
whereas  on  the  concave  they  are  flattened  out,  and  in  severe 


Fig.  24. — Paralytic  general  kypho-scoliosis  in  a  boy  aged  three. 


cases  all  semblance  of  joint  structure  has  disappeared  and 
they  have  become  anchylosed.  The  transverse  processes 
are  altered  in'  shape  and  direction,  sometimes  they  have 
become  joined  to  their  neighbours,  and  occasionally  they 
are  elongated  on  the  convex  side.  The  spinous  processes 
are  variously  altered  in  shape,  and  their  apices  are  usually 
directed  to  the  concave  side,  but  sometimes  in  the  opposite 


54  BODILY   DEFORMITIES. 

direction.  The  lamina  are  found  to  vary  in  different  cases, 
being  sometimes  thicker  laterally  on  the  concave  side, 
sometimes  being  smaller  in  all  directions  on  the  same 
side,  and  at  other  times  there  is  no  appreciable  difference 
between  the  convex  and  concave  sides.  The  vertebral 
foramina  are  sometimes  much  contracted  on  the  concave 
side,  and  enlarged  and  triangular  on  the  convex.  The 
vertebral  arches  have  their  pedicles  shorter  on  the  concave 
side,  and  in  extreme  cases  the  articular  processes  are  in 
contact  with  the  vertebral  bodies ;  in  other  cases  the 
pedicles  are  altered  in  all  their  dimensions  but  without  any 
great  regularity. 

Besides  these  changes  in  individual  vertebrae,  there  exists 
a  rotation  and,  in  severe  cases,  a  torsion  on  an  antero- 
posterior axis  of  the  affected  vertebral  segments,  and  the 
rotation  has  taken  place  around  one  or  more  of  the  articular 
processes  as  centres.  This  rotation  varies  with  the  direction 
of  the  curvature,  as  it  takes  place  from  the  concave  towards 
the  convex  side,  and  during  life  it  would  only  be  inferred 
by  the  experienced,  as  its  effect  is  much  less  pronounced  on 
the  parts  open  to  examination,  such  as  the  spinous  processes 
and  the  vertebral  arches,  than  on  the  bodies.  This  mixed 
rotation  and  torsion  is  most  marked,  as  might  be  expected, 
at  the  most  salient  part  of  the  curve. 

Certain  well-marked  secondary  deformities  of  the  thoracic 
parietes  are  found  in  all  well-marked  cases  of  this  distortion. 
In  moderately  severe  cases,  the  ribs  corresponding  to  the 
affected  vertebrae  become  separated  from  each  other  on  the 
convex  side  and  the  opposite  on  the  concave,  so  that  in 
severe  cases  they  touch  and  even  over-lap,  and  sometimes 
become  anchylosed.  They  are  displaced  backwards  on  the 
convex  side,  and  their  head  and  neck  are  altered  in  shape  ; 
in  severe  cases  the  former  is  absorbed  •  or  anchylosed  with 
the  corresponding  vertebra,  and  the  angles  and  posterior 


CURVATURES    OF    THE    SPINE.  55 

parts  of  the  rib-arches  form  a  projection  at  the  back  of  the 
thorax  which  may  be  confounded  with  the  deformity  due 
to  cyphosis,  or  to  Pott's  disease,  but  differs  from  them  in 
that  the  protuberance  of  the  latter  is  more  or  less  in  a  line 
with  the  vertebral  segments,  whereas  the  costal  scoliotic 
deformity  is  to  one  side,  and  on  the  side  corresponding  to 
the  curvature,  and  therefore  usually  in  the  right  dorsal  or 


Fig.  25. — Thorax  from  a  case  of  scoliosis.    (Henke.) 

left  lumbar  regions,  as  this  is  the  most  common  form  of 
idiopathic  scoliosis.  On  the  concave  side,  the  posterior 
parts  of  the  rib-arches  and  angles  are  depressed,  causing  a 
flattening  of  the  posterior  thoracic  wall,  whereas,  in  front, 
the  costal  cartilages  form  a  projection,  while  on  the  convex 
side  there  is  a  corresponding  flattening.  It  will  thus  be 
observed  that  there  is  a  projection  and  a  flattening  on  both 
sides,  a  posterior  projection  and  an  anterior  flattening  on 


56  BODILY   DEFORMITIES. 

the  convex  side  of  the  groove,  and  vice  versa  on  the  con- 
cave. 

The  sternum  is  sometimes  convex  in  front  and  at  other 
times  concave,  and  the  xyphoid  cartilage  may  be  depressed 
or  the  reverse.  At  other  times  it  may  incline  to  one  side 
or  the  other,  or  be  obliquely  placed.  The  alterations  of 
the  sternum  are  dependant  upon  the  diminished  length  of 
the  thorax.  The  interior  of  the  thoracic  cavity  becomes 
considerably  altered  in  shape  and  size,  as  is  well  shown  by 
transverse  sections  which  clearly  display  the  groove  formed, 
in  severe  cases,  behind  the  spine  on  the  convex  side  of  the 
curve.  This  is  due  to  the  backward  displacement  of  the  ribs 
and  the  alteration  of  the  costal  angles  on  the  affected  side, 
and  if  the  case  be  a  very  bad  one,  the  ribs  will  be  found  in 
contact  with  the  vertebral  bodies,  and  this  groove  will  be 
absent.  The  pleural  cavities  will  also  be  altered  in  size 
and  shape,  being  much  contracted  on  the  side  correspond- 
ing to  the  deformity ;  this  is  due  to  the  anterior  flattening 
of  the  costal  arches  on  the  side  corresponding  to  the  cur- 
vature, and  to  the  greater  obliquity  of  the  ribs  from  before 
backwards  and  downwards  on  the  affected  side.  On  the 
concave  side  the  pleural  cavity  is  enlarged  to  the  extent  of 
the  degree  of  the  spinal  concavity,  and  of  the  anterior 
bulging  of  the  ribs  and  cartilages ;  but  this  enlargement 
is  to  a  great  extent  counteracted  by  the  dimensions  of  the 
cavity  in  other  directions,  and  especially,  perhaps,  by  the 
posterior  flattening  of  the  costal  arches. 

Thoracic  Viscera. — As  would  naturally  be  expected, 
these  bony  changes  interfere  with  the  contained  viscera; 
and  the  lungs,  as  occupying  the  largest  portion  of  the 
space,  and  in  consequence  of  their  consistence,  suffer 
the  greatest  alteration  in  shape  and  in  function,  and  next 
to  these  comes  the  heart.  Both  lungs  are  diminished 
in   size,   though    the    greater  change    is    found   in    that 


CURVATURES    OF   THE    SPINE.  57 

occupying  the  convex  side,  so  that  in  most  cases  the  right 
lung  is  the  smaller.  If  compressed  in  all  directions 
between  the  spine  and  ribs,  its  posterior  border  becomes 
thin  and  flattened  in  the  retro-spinal  groove  already  spoken 
of,  and  the  left  one  is  flattened  posteriorly,  corresponding  to 
the  shape  of  the  ribs  on  the  concave  side.  The  changes  in 
the  diaphragm,  presently  to  be  described,  also  cause  changes 
in  the  shape  of  the  lungs,  so  that  in  cases  of  great  deformity, 
pathological  changes  must  and  do  occur  in  the  lung  struc- 
ture and  function,  causing  hyperaemia,  consolidation,  em- 
physema, &c.  The  trachea  and  bronchi  are  altered  in 
direction  and  size,  and  the  bronchus  corresponds  in  condi- 
tion to  that  of  the  lung  to  which  it  goes,  and  similar  and 
corresponding  changes  are  found  in  the  pulmonary  arches. 

In  consequence  of  the  change  in  position  of  the  diaphragm, 
the  heart  is  generally  displaced  upwards  and  to  the  left, 
though  in  the  majority  of  cases  it  has  not  much  deviated 
from  its  normal  position.  In  severe  cases  of  left  lateral 
curvature,  the  space  for  the  heart  is  diminished,  so  that  it 
is  hampered  in  its  action ;  but  in  such  cases,  especially  in 
later  stages,  the  heart  rests  in  the  concavity  of  the  groove. 
The  size  of  this  organ  may  be  normal,  or  it  may  be  hyper- 
trophied,  and  in  cases  where  the  lungs  are  much  interfered 
with,  secondary  changes,  amounting  in  some  cases  to  marked 
incompetence,  will  result,  and  these  will  react  upon  the  lungs 
producing  severe  dyspnoea,  palpitation  and  other  alarming 
symptoms.  The  aortic  arch  is  shorter  than  natural  and 
corresponds  to  the  spinal  curve,  and  in  severe  cases  there 
is  a  fold  on  it  on  the  concave  side,  and  a  dilatation  on 
the  convex ;  and  in  bad  cases  of  left  lateral  curvature  the 
arch  and  a  large  part  of  the  aorta  may  be  found  entirely  on 
the  right  side.  The  vessels  springing  from  the  heart  undergo 
corresponding  changes.  The  venae  cavae  are  found  enlarged, 
the  inferior  may  have  undergone  displacement  correspond- 


58  BODILY   DEFORMITIES. 

ing  to  that  of  the  aorta,  and  in  severe  cases  will  be  found 
quite  away  from  the  spine.  It  will  be  readily  understood 
from  these  changes  in  the  heart  and  enlarged  vessels,  that 


fa 


a   languid    circulation,   cold    extremities,   and  visceral   or 

peripheral  congestion,  are  not  very  uncommon  phenomena. 

The  oesophagus  corresponds  in  curvature  to  that  of  the 


CURVATURES    OF   THE    SPINE.  59 

spine  in  ordinary  cases,  but  in  severe  cases  it  leaves  the 
spine  altogether,  and  passes  straight  down  to  the  stomach. 
It  is  well  that  this  is  the  case,  and  it  explains  the  absence 
of  dysphagia  in  severe  cases  of  the  disease. 

Abdominal  Viscera. — The  diaphragm  is  pushed  up 
through  the  displacement  of  the  abdominal  viscera,  and 
through  the  alteration  and  position  of  its  costal  and  sternal 
attachments,  its  foramina  are  altered  in  shape,  size,  and 
position,  but  usually  not  sufficiently  to  interfere  with  the 
transmitted  organs. 

The  abdominal  cavity  is  contracted  in  its  dimensions,  so 
that  the  viscera  cause  the  anterior  abdominal  wall  to  project 
and  also  push  up  the  diaphragm,  but  the  stomach  and  in- 
testines are  usually  displaced  downwards,  and  the  liver, 
which  may  be  diminished  or  congested  through  interference 
with  its  circulation,  is  altered  in  shape  at  its  lower  and  back 
part  on  the  deformed  side.  The  spleen,  if  not  displaced 
downwards,  is  usually  smaller  than  natural ;  the  kidneys 
lose  their  normal  level,  following  the  rule  of  the  other  solid 
abdominal  viscera  in  cases  where  the  abdominal  portion  of 
the  spine  is  much  deviated.  The  kidney  on  the  convex 
side  of  the  curve  is  usually  smaller  than  that  on  the  con- 
cave, which  undergoes  a  compensatory  hypertrophy.  The 
abdominal  aorta  also  in  similar  cases  will  undergo  corre- 
sponding deviations  in  form  and  relations. 

The  pelvis  and  contained  viscera  become  affected  in 
severe  or  in  long  standing  cases,  and  in  such  the  lumbar  cur- 
vature will  extend  to  the  sacrum  and  coccyx,  and  the  vertebral 
segments  composing  them  will  have  undergone  correspond- 
ing changes,  being  more  developed  on  the  convex  than  on  the 
concave  side.  There  will  also  be  corresponding  changes  in 
the  pelvic  diameters,  pelvic  obliquity  will  exist,  and  a  rotation 
from  behind  forwards  and  downwards,  so  that  the  anterior 
superior  spines  will  be  found  on  different  levels  from  above 


60  BODILY   DEFORMITIES. 

downwards,  and  from  before  backwards.  The  pelvic  inlet 
will  be  diminished,  i.e.,  the  antero-posterior  diameter  at 
the  true  pelvic  brim  will  be  lessened,  and  this  change  will 
be  greater  on  the  convex  side  of  the  curve.  Such  changes 
may  be  found  in  cases  of  severe  lumbar  curvature,  whether 
this  be  primary  or  secondary.  Though,  as  already  stated, 
in  some  bad  cases  there  is  a  marked  alteration  of  the  pelvic 
inclination,  it  is  the  exception,  and  the  rule  is,  that  the 
alteration  in  position  of  the  ilia  and  the  hip  projection  are 
apparent  rather  than  real.  These  pelvic  changes  in  females 
are  of  great  practical  importance,  as  they  may  cause  difficult 
labours. 

The  spinal  cord,  occupying  as  it  does  the  larger  part  of 
the  canal,  i.e.  on  the  concave  side,  does  not  become  com- 
pressed, and  the  contraction  of  the  intervertebral  foramina 
does  not  proceed  to  the  compression  of  the  nerves  suffi- 
ciently to  obliterate  their  avenues,  though  it  may  cause 
symptoms  of  irritation,  neuralgia,  cramps,  &c. 

The  spinal  muscles  become  secondarily  affected.  They 
are  relaxed  on  the  concave  side,  and  stretched  on  the  oppo- 
site. In  both  cases,  from  inactivity,  they  become  fattily 
degenerated,  though  it  is  only  in  extreme  cases  that  they 
are  incapable  of  producing  a  fair  amount  of  motion. 

The  Pelvic  Viscera  may,  and  especially  in  females  do 
suffer  through  the  bony  deformity.  I  have  known  uterine 
displacements  and  rectal  and  bladder  troubles  to  be 
directly  due  to  these  conditions,  and  it  is  hardly  necessary 
to  state  that  unless  something  can  be  done  to  improve  the 
position  of  the  spine,  the  treatment  of  such  cases  is  any- 
thing but  satisfactory. 

Course  and  Prognosis. — These  will  depend  upon  the 
predisposing  cause,  and  upon  the  state  of  the  deformity 
when  the  patient  is  first  seen  ;  but  often  a  good  deal  may  be 
done  if  treatment  be  sought  before  the  final  stages  of  fixity 


CURVATURES    OF   THE    SPINE. 


61 


of  the  deformity  have  commenced,  or  proceeded  to  any 
extent.  Cases  of  lateral  curvature  differ  in  severity,  some, 
even  without  treatment,  never  passing  beyond  the  stage  of 
slight  deformity,  while  others  rapidly  go  on  to  extreme  dis- 
tortion. The  prognosis  involves,  first  the  curability  of  the 
deformity ;  seco?idly,  the  consideration  of  any  changes  it 
may  have  produced  upon  the  viscera.  In  ordinary  cases, 
which  are  fortunately  the  majority,  there  is  no  great  diffi- 
culty in  affording  relief  to  the  deformity  as  well  as  to  the 


Fig.  28. — To  show  how  a  curve  can  be  produced,  or  how  an  existing  one  can  be 
corrected  by  lateral  decubitus  and  the  use  of  pillows. 

pain  and  inconvenience  it  sometimes  produces  ;  but  in  the 
more  extreme  cases,  where  the  deformity  is  very  pro- 
nounced, the  viscera,  as  already  stated,  are  seriously  inter- 
fered with,  and  the  prognosis  is  necessarily  more  seriouSj 
and  especially  if  the  deformity  be  in  the  thoracic  portion 
of  the  spine,  as  it  often  is. 

If  the  subject  be  young,  and  there  be  but  a  single  curva- 
ture, one  may,  with  appropriate  treatment,  be  sanguine  of 


62  BODILY   DEFORMITIES. 

cure ;  but  if  a  secondary  curve  be  established,  the  correc- 
tion of  the  deformity  is  anything  but  easy,  and  if  the  case 
have  proceeded  to  any  considerable  rotation  of  the  vertebrse 
the  result,  as  regards  correction  of  the  deformity,  according 
to  past  methods  of  treatment,  is  usually  not  a  good  one. 
But  I  have  seen  enough  to  be  able  to  say  that  appropriate 
gymnastic  and  hygienic  methods,  combined  with  proper 
supports  between  whiles,  may  do  much  good  even  in  these 
cases.  With  properly  constructed  instruments,  severe 
lateral  curvature  of  the  column  may  be  to  some  extent 
corrected,  but  the  rotation  little,  if  at  all,  affected. 

Treatment. — This  may  be  divided  into  prophylactic 
and  therapeutic ;  in  the  former  our  aim  should  be  to 
instruct  parents  and  the  public  generally,  and  especially  the 
heads  of  schools,  on  the  importance  of  providing  properly 
constructed  writing  desks  and  stools,  and  also  on  the  value 
of  well  devised  gymnastic  exercises,  especially  in  the  case 
of  young  girls.  I  feel  sure  we  should  see  less  of  lateral 
curvature  in  the  upper  and  lower  classes  were  the  evil  con- 
sequences of  bad  habits  of  position,  whether  in  standing 
or  sitting,  made  known  to  the  pupils  and  to  their  friends. 
The  prophylaxis  of  lateral  curvature  has  been  given  in  the 
introductory  chapter. 

The  second  division  of  the  subject,  viz.,  surgical  treat- 
ment proper,  involves  the  consideration  of  gymnastic  exer- 
cises, massage,  electricity,  the  use  of  various  appliances, 
and  the  necessity  of  rest  where  this  is  clearly  indicated. 
Of  course  it  must  be  understood  that  each  case  must  be 
treated  on  its  merits,  and  this  is  a  matter  of  no  great  diffi- 
culty to  the  experienced ;  but  for  the  guidance  of  prac- 
titioners I  will  concisely  lay  down  a  few  rules  applicable  to 
the  majority  of  cases.     First,  then,  as  regards  rest. 

Rest. — Should  there  be  much  pain,  patients  must  be  made 
to  rest  in  the  dorsal  position,  and  when  this  becomes  irk- 


CURVATURES    OF   THE    SPINE. 


63 


some,  they  may  lie  in  the  prone  position,  and  the  couch  or 
bed  should  be  covered  with  a  firm,  somewhat  hard  mattress, 
and  it  is  well  to  put  two  blocks  underneath  the  legs  of  the 
bed  near  the  head  so  as  to  bring  the  body  into  an  inclined 
position.  Much  may  be  done  by  the  assumption  of  a 
suitable  position  in  bed,  or  while  resting  on  a  couch  during 
the  day,  and  the  illustration  Fig.  28  sufficiently  explains 
this. 

The  couch  recently  recommended  by  Mr.  Lund,  of 
Manchester,  in  the  British  Medical  Journal,  appears 
to  be  very  serviceable.  If  the  patients  be  quite  young,  it 
may  be  necessary  to  pass  a  broad  bandage  over  the  chest 


Fig.  29. — Apparatus  for  extension  and  counter-extension  in  lateral  curvature  by  the 
body  weight  during  recumbency. 


and  fasten  it  down  to  the  sides  of  the  couch  or  bed,  but, 
occasionally,  for  a  quarter  or  half  an  hour  at  a  time  during 
the  day,  they  may  be  allowed  to  sit  up,  their  backs  well 
propped  with  pillows  or  by  a  bed  rest ;  older  patients 
should  be  allowed  to  have  nine  or  ten  hours  sleep  and  to 
rest  occasionally  during  the  day.  When  the  dorsal  or 
prone  decubitus  is  ordered,  a  board  a  little  longer  and 
broader  than  the  patient  should  be  placed  underneath  the 


64  BODILY    DEFORMITIES. 

mattress,  but  the  lateral  decubitus  is  very  serviceable  in  not 
a  few  cases  of  scoliosis,  and  Wolff  has  devised  a  sus- 
pensory cradle  which  I  can  strongly  recommend  and  which 
is  shown  in  the  accompanying  engraving.  After  a  time 
the  patients  get  used  to  it,  and  I  have  found  that  it  not 
only  relieves  pain,  when  present,  but  is  a  valuable  aid  in  the 
correction  of  the  deformity  during  the  day  or  night.  The 
figure  teaches  how  this  simple  apparatus  should  be  used.  As 
cases  of  right  dorsal  lateral  curvature  are  the  commonest,  it 
is  this  portion  that  is  represented  as  being  extended  by  the 
swing  or  cradle.  Though  simple,  this  apparatus  acts  bene- 
ficially by  correcting  the  lumbar  curve  through  the  natural 
weight  of  the  parts  between  the  buttocks  and  thorax  band  ; 
by  pressing  on  the  dorsal  curve  and  on  the  deformed  chest, 
and  thus  forcing  the  other  half  of  the  chest  to  increased 
respiratory  efforts,  allowing  of  respiratory  gymnastics  while 
resting. 

Gymnastics. — This  part  of  the  treatment,  so  essential 
in  suitable  cases,  may  be  divided  into  active  and  passive. 
In  the  former,  the  patients  have  to  execute  the  exercises 
themselves ;  in  the  latter,  they  are  done  by  a  properly 
trained  assistant.  As  there  are  various  methods,  it  will  be 
out  of  place  here  to  enter  at  length  into  them,  and  at  pre- 
sent I  shall  content  myself  with  pointing  out  those  means 
and  exercises  which  experience  has  taught  me  to  be  of 
great  service.  I  shall  reserve  a  fuller  description  for  a 
separate  publication. 

Orthopaedic  gymnastics  may  be  carried  out  with  or 
without  the  use  of  apparatus,  and  though  I  have  found  that 
the  simpler  forms  of  apparatus  effect  considerable  benefit 
in  suitable  cases,  still  I  think  there  are  other  cases  which 
are  benefited  by  exercises  with  apparatus.  Among  the 
latter  I  would  lay  some  stress  on  auto-suspension,  i.e.,  hang- 
ing by  the  arms  from  a  parallel  bar  by  which  means  the 


CURVATURES    OF   THE    SPINE.  65 

body-weight  extends  the  spine.  This  exercise  may  be 
repeated  by  patients  strong  enough  to  bear  it  two  or  three 
times  daily,  and  an  assistant  may  steadily  pull  at  the  legs, 
or  a  weight  may  be  attached  to  them.  The  patient  while 
taking  this  exercise  should  not  allow  the  arms  to  be  com- 
pletely extended,  and  when  sufficiently  expert,  should  flex 
and  extend  the  elbows  so  as  to  raise  and  depress  the  chin 
alternately  above,  and  below,  the  trapeze  or  horizontal  bar. 

Going  hand  over  hand  up  and  down  a  ladder  is  an 
excellent  exercise,  and  sometimes  the  patient  should  go  up 
and  down  with  fully  extended  arms,  and  at  others  with 
flexed  elbows,  and  this  exercise  may  be  done  with  the  hands 
alternately,  or  simultaneously  with  the  two,  jumping,  as  it 
were,  up  and  down.  But  this  can  only  be  done  after  a 
certain  -amount  of  practice.  With  the  trapeze  or  the 
gymnastic  rings,  the  patient  may  swing  backwards  and  for- 
wards, bringing  the  abdominal  and  pelvic  muscles  into  play 
and  thus  serving  to  extend  the  spine.  With  the  parallel 
bars,  the  patient  may  stand  between  them  at  their  entrance 
and  thus  expand  the  chest,  or  he  may  raise  and  depress  the 
body  while  standing  between  the  bars. 

Self -suspension  may  be  usefully  applied  in  appropriate 
cases  by  some  modification  of  Sayre's  apparatus  or  that 
of  Beely,  and  it  may  be  cephalic  or  axillo-cefihalic,  that  is 
to  say,  the  lifting  apparatus  may  be  fixed  to  the  occiput 
and  chin,  or  to  these  and  to  the  axilla.  In  the  former,  the 
effect  on  the  spine  is  naturally  greater  than  in  the  latter, 
but  less  care  and  practice  are  requisite  in  the  latter  than  in 
the  former.  It  must  be  clearly  understood  that  these 
exercises  must  be  gradually  increased,  and  never  continued 
till  muscular  or  articular  pains  be  produced,  or  until  the 
patient  becomes  fatigued.  I  may  mention  that  the  use  of 
the  couch  of  Pravaz  is  an  excellent  method  of  taking 
gymnastic  exercises  in  the  recumbent  position.     The  couch 

F 


66 


BODILY    DEFORMITIES. 


acts  passively  in  the  direction  of  pressure  and  extension,  as 
do  the  so-called  orthopaedic  beds,  and  the  curves  of  the 
couch  correspond  to  those  of  ordinary  scoliosis.  The 
patient  lying  upon  her  or  his  side,  and  slightly  inclined  to 
the  dorsal  decubitus,  arranges  herself  so  that  the  convexity 
of  the  dorsal  curve  is  applied  to  the  convexity  of  the  couch, 
while  the  left  arm,  which  of  course  corresponds  to  the  con- 
vexity of  the  curve,  works  the  apparatus.     Pravaz's  couch 


Fig.  30. — Diagram  of  the  action  of  the  lateral  curvature  cradle  on  the  thorax. 


was  constructed  to  run  on  rails  like  a  miniature  tramway, 
but  if  the  wheels  be  covered  with  rubber,  they  may  be  used 
in  any  room  sufficiently  large,  and  without  the  use  of  rails. 
Swimming  is  also  a  good  exercise  in  suitable  weather, 
and  in  the  metropolis  it  is  quite  easy  for  the  patient  to  have 
tepid  swimming  baths,  and  should  she  be  unable  to  swim, 
the  exercise  of  learning  is  accompanied  with  interest  and 
with  benefit.  Should  for  any  reason  water  immersion  be 
contra-indicated,  dry-swimming,  or  swimming  exercise  in 
the  air,  is  a  good  gymnastic  means.  The  patient  should 
rest  the  abdomen  on  a  mattress  or  air  cushion  sufficiently 
high  to  allow  flexion  and  extension  of  the  knees,  and  the 
exercise  should  be  practised  in  the  ventral  and  dorsal  posi- 


CURVATURES    OF   THE    SPINE.  67 

tions  for  ten  minutes  two  or  three  times  a  day.  Jahn,  of 
Germany;  Ling,  of  Sweden,  and  others  have  devised 
systems  of  gymnastics  which  have  become  renowned,  and 
though,  in  proper  cases,  there  can  be  no  doubt  that  rational 
gymnastics,  selecting  those  exercises  which  anatomy  and 
physiology  combined  with  experience  teach  to  be  good,  has 
been,  and  will  continue  to  be,  of  the  greatest  service  ;  still, 
unfortunately,  and  chiefly  I  think,  through  professional 
neglect  of  these  valuable  auxiliaries,  the  door  has  been 
opened  to  quackery,,  so  that  some  have  gone  the  length  to 
pretend  to  cure  cancer  by  these  means.  The  exercises 
in  these  two  methods,  as  well  as  in  other  variants,  are 
numerous,  though  but  a  few  are  really  necessary  for  our 
purposes.  Some  of  them  are  carried  on  through  the 
ordinary  gymnastic  machines,  others  by  the  hands  of 
trained  gymnasts,  forming  passive  gymnastics,  and  others 
constitute  mixed  or  double  movements,  combining  active 
and  passive  gymnastics.  Zander  has,,  during  the  last  few 
years,  constructed  most  ingenious  machines  to>  replace  the 
use  of  a  trained  gymnast ;  but  excellent  as  these  are,  I 
cannot  think,  from  what  I  have  seen  of  them,  that  they  can 
be  in  the  majority  of  cases  effective  substitutes  for  an 
intelligent  human  guide. 

The  methods  in  these  forms  of  gymnastics  may  be 
divided  into  the  voluntary  or  active,  the  pasdve,  and  the 
double  or  combined  7novements.  The  first  are  executed  by 
the  patient,  the  second  by  the  gymnast,  and  the  combined, 
necessitate  activity  on  the  part  of  the  gymnast  and  the 
patient.  If  the  patient  voluntarily  execute  a  movement 
and  be  resisted  by  a  gymnast,  the  exercise  is  termed  double 
concentric;  but  if  the  gymnast  make  a  movement  which  is 
resisted  by  the  patient,  this  is  termed  the  double  eccentric 
exercise.  The  parent  idea  which  gave  birth  to  these 
forms  of  gymnastics  was  the  antagonistic  theory,  already 

f  2 


6&  BODILY    DEFORMITIES. 

explained,  and  often  found  wanting,  and  it  was  thought  that 
these  exercises  would  recover  tone  to  the  weakened  and 
relaxed  muscles ;  but  it  must  be  borne  in  mind  that  the 
views  of  orthopaedists  have  varied  as  to  which  muscles  are 
relaxed,  whether  those  of  the  convex  or  the  concave  side. 
That  those  on  the  convex  are  hyper-extended,  there  can  be 
little  doubt,  and  also,  I  think,  all  will  agree  that  this  must 
affect  their  nutrition.  That  those  on  the  concave  side  are 
affected  with  nutritive  shortening  and  degeneration,  has 
already  been  shown,  but  in  this  connection  it  must  be 
recollected  that  excellent  as  these  exercises  are,  they  are 
only  suitable  to  proper  cases,  viz. — those  in  the  first  stage, 
or  those  in  the  earlier  degrees  of  the  secondary  stage.  Of 
course,  when  there  is  little  or  no  mobility  in  the  spine, 
little  or  nothing  can  be  expected  from  gymnastics ;  but  it 
should  be  borne  in  mind  that  even  if  little  can  be  done  to 
correct  the  spinal  deviation,  as  in  the  tertiary  stages,  still 
the  exercises  often  benefit  the  general  health,  and  so  far 
are  to  be  strongly  recommended  in  suitable  cases.  Think- 
ing, as  I  do,  that  many  cases  of  statical  scoliosis  are  due 
to  altered  and  perverted  vertebral  pressure,  with  or  without 
bone  changes,  such  as  softening,  it  might  be  thought  that 
little  could  be  gained  from  gymnastics ;  but  this  would  be 
an  error,  as  I  have  seen  cases  which,  in  the  early  stages 
at  least,  have  derived  marked  benefit  both  as  regards  the 
curvature,  and  as  concerns  the  general  health. 

Although  the  parent  idea,  as  already  pointed  out,  is 
false,  the  method  is  very  useful,  though  the  reason  of  its 
application  is  different.  Ling  and  his  pupils  sought  to  re- 
establish muscular  equilibrium  by  fortifying  the  relaxed 
muscles  on  the  concave  side  by  exercising  them,  and  to 
effect  this,  he  brought  into  play  the  muscles  on  the  convex 
side,  and  thus  sought  to  cure  or  benefit  the  curvature. 
Thus  it  will  be  seen  that  Swedish  medical  gymnastics  or 


CURVATURES    OF   THE    SPINE.  69 

kinesitherapie  is  really  a  form  of  local  muscular  exercise ; 
and  it  would  appear  that  the  Frenchman  Lachaise  had 
conceived  somewhat  similar  views  antecedent  to  Ling. 

Massage  may  be  also  either  active  or  passive,  and  is 
but  a  branch  of  gymnastics,  kinesitherapie  or  dynamo- 
therapeutics,  and  consists  of  shampooing,  kneading,  rub- 
bing, frictions,  or  muscle-beating,  combined  with  the  use, 
if  necessary,  of  various  kinds  of  hot  and  cold  douches. 
Its  applications  are  numerous  and  valuable  in  suitable 
cases,  but  I  must  defer  a  fuller  description  for  another  time 
and  place. 

Electricity,  judiciously  employed,  in  its  various  forms, 
is  of  undoubted  service  in  the  treatment  of  lateral  curva- 
ture. It  may  be  applied  in  the  interrupted  or  continued 
current,  the  latter  having  yielded  me  better  results.  One 
electrode  should  be  applied  in  the  mid-line  over  the  spine, 
and  the  other  to  the  muscles  on  the  convex  side  of  the 
curve,  and  also  to  the  respiratory  muscles.  The  ascending 
current,  if  the  continuous  form  be  used,  seems  to  be 
preferable.  Mr.  De  Watteville's  work  will  be  found  to  be 
a  valuable  guide  in  carrying  out  electrical  treatment. 

Mechanical  Apparatus.— These  may  be  divided  into 
spinal  beds  and  spinal  supports.  Orthopaedic  beds,  whether 
mechanical,  or  by  making  the  patient  lie  on  inclined  planes, 
are  but  little  used  now-a-days,  and  I  think  this  is  a  pity, 
because  there  can  be  little  doubt  that  in  suitable  cases  a 
modification  of  these  beds  or  couches  is  of  service.  The  great 
price  of  the  old  couches  was  a  serious  drawback,  but  now- 
a-days  an  apparatus  in  which  a  patient  may  lie  can  be  con- 
structed at  a  moderate  cost.  These  machines  may  com- 
bine the  actions  of  pressure  and  extension,  and  such 
appear  to  be  preferable.  I  need  only  mention  a  modern 
form  of  this  apparatus,  which  is  Hueter's  modification  of 
Biihring's  apparatus. 


70  BODILY    DEFORMITIES. 

The  sloping  seat  recommended  by  Bouvier,  and  subse- 
quently by  Volkmann  and  Bar-well,  is  useful  in  some  cases, 
but  its  use  must  be  combined  with  orthopaedic  gymnastics, 
massage,  &c.  If  there  be  pes  valgus  and  atonic  genu 
valgum,  a  valgus  sole  plate  and  an  instrument  to  gradually 
correct  the  knock-knee  must  be  worn. 

Spinal  Supports  and  Corsets.— The  object  of  these 
should,  in  my  opinion,  be  to  keep  the  spine  in  an  amended 
or  corrected  position  between  the  intervals  of  gymnastic 
exercises.  Very  numerous  forms  have  been  constructed, 
and  it  is  not  necessary  to  enter  into  these,  especially  as 
many  are  quite  obsolete.  The  idea  of  them  is  to  act  with 
sufficient  force  in  the  right  direction,  so  as  to  correct  the 
flexion  and  rotation  of  the  vertebrae,  and,  as  the  ensuing 
figures  will  show,  they  act  upon  the  ribs,  using  these  as 
levers  to  correct  spinal  flexion  and  torsion.  It  would,  no 
doubt  be  better,  if  the  pads  were  brought  nearer  the  spine, 
so  as  to  act  more  directly  upon  the  vertebral  column. 

These  instruments  may  be  divided  into  various  classes, 
such  as  those  which  act  by  extension  only,  through  arm- 
crutches,  taking  the  fixed  point  at  the  pelvis,  and  such  are 
only  suitable  to  mild  cases ;  others  which  act  through  ex- 
tension and  lateral  pressure ;  others  which  combine  these 
movements ;  others  which  cause  an  inclination  of  the 
spine  in  an  opposite  direction  to  the  deformity,  and  yet 
others  which  act  on  the  principle  of  flexion.  In  cases 
where  a  support  is  really  necessary,  it  is  advisable  to  com- 
bine most  of  these  movements,  and  herein  arises  the 
mechanical  difficulty  of  making  a  light  yet  effective  support ; 
and  when  I  use  the  term  support  I  mean  a  spinal  corrector. 
Before  describing  those  which  I  have  found  the  most 
serviceable,  I  will  say  a  few  words  about  the  treatment  of 
the  second  and  third  stages  of  scoliosis  by  means  of  elastic 
bandages;  and  I  will   at   once   state   that  I  have  never 


CURVATURES    OF   THE    SPINE.  7 1 

ordered  them,  not  believing,  theoretically,  in  the  power  of 
the  elastic  bandages  of  Mr.  Barwell  to  correct  the  defor- 
mity, for  I  have  seen  several  cases  that  have  worn  them 
for  years  without  the  least  benefit.  I  do  not  wish  to  state 
anything  that  will  not  bear  the  strictest  analysis,  and,  there- 
fore, I  would  at  once  remark  that  some  of  these  cases  would 
have  been  but  little  benefited  by  any  form  of  apparatus, 
and  therein  consists  my  wonder  that  any  effect  could  have 
been  expected  from  the  force,  so  comparatively  slight,  which 
these  bandages  exert.  I  think,  however,  that  in  incipient 
cases  they  may  prove  serviceable  as  spinal  reminders,  and 
thus  educate  the  patient  to  keep  the  spine  erect. 

The  following  figure  represents  Hossard's  apparatus 
applied  to  a  right  dorsal  predominating  curve,  and  its 
action  is  sufficiently  obvious.  It  was  fully  described  by 
Tavarnier  in  1841,  and  almost  all  subsequent  instruments 
have  been  constructed  chiefly  on  its  model  Eulenburg's 
instrument  is  a  modification  of  this,  but  in  practice  it  has 
been  found  that  the  rachet  arrangement  is  difficult  to  fix 
so  as  to  avoid  pressure  upon  the  spinous  processes.  I 
cannot  help  agreeing  with  Vogt  that  Hossard's  instrument 
would  tend  rather  to  increase  than  to  diminish  the  defor- 
mity, seeing,  as  the  annexed  figure  will  show,  that  there  is 
no  provision  for  correction  of  the  vertebral  torsion.  That 
it  will  incline  the  spine  there  is  no  doubt,  but  that  it  will 
permanently  correct  the  deformity  is  more  than,  from  its 
mechanical  construction,  we  can  expect. 

Guerin  had  an  instrument  constructed  to  act  on  the 
principle  of  contra-flexion.  This  apparatus  is  provided 
with  an  arm-crutch  on  one  side  only,  and  it  seems  to  me 
on  the  wrong  side,  if  the  scoliosis  be  statical,  and  the  pre- 
dominating curve  on  the  right.  I  think  it  will  be  obvious 
that  a  machine  combining  what  experience  teaches  to  be 
useful  in  these  apparatuses,  will  recommend  itself  to  prac- 


72 


BODILY    DEFORMITIES. 


titioners  as  serviceable,  and  I  will  presently  describe  such 
an  one,  but  before  doing  so  will  say  a  few  words  concerning 
the  plaister-of-paris  jacket. 

The  Plaister  Jacket. — It  is  not  necessary  to  append 
illustrations  of  the  various  modes  of  applying  Sayre's 
jacket      The   methods  of  extension   and   of  the   use  of 


Fig.  31.— Hossard's  spinal  inclination  corrector  applied  to  a  right  upper  dorsal  curve. 


the  jacket  are  now  well  known,  and  are  figured  in  his 
and  other  books  on  orthopaedic  surgery;  but  seeing  that 
they  have  very  largely  fallen  into  desuetude,  and,  moreover, 
as  at  the  meeting  of  the  International  Medical  Congress 
in  London  in  1881,  I  showed  the  fallacy  of  this  method 
of  treatment  in  lateral  curvature,  I  need  not  dwell  further 
on  it  than  to  say  that,  in  hospital  practice,  where  expense 


CURVATURES    OF   THE    SPINE.  73 

is  an  object,  a  modification  of  his  plan  will  be  of  service  in 
certain  cases  of  scoliosis.  In  brief,  the  method  is  this  :  when 
the  plaister  bandages  are  applied,  thick  pads  should  fill  in 
the  concavity  of  the  curve,  and  when  the  plaister  is  moist, 
holes  corresponding  to  these  should  be  cut  out  of  the  jacket. 
Of  course  the  jacket  should  be  applied  to  the  patient  in 
the  extended  position,  and  then  be  allowed  to  set.  The 
pads  can  then  be  removed,  and  space  is  permitted  for  ex- 
pansion of  the  chest  and  of  the  concavity  of  the  curve. 
I  only  mention  this  as  helpful  in  hospital  and  pauper 
practice,  and  I  warn  those  using  it,  not  to  expect  any  per- 
manent benefit  in  lateral  curvature,  though  in  slight  and 
incipient  cases,  it  is  an  inexpensive  adjuvant  not  to  be 
overlooked  when  combined  with  the  other  methods  already 
described.* 

The  best  form  of  the  usual  spinal  supports  is  represented 
in  the  accompanying  figure,  and  consists  of  a  pelvic  band, 
taking  its  fixed  point  on  the  iliac  crest,  and  encircling  the 
buttocks  somewhat  lower  down ;  to  this  band  two  crutches 
are  fixed,  and  as  these  can  be  extended  or  lowered  accord- 
ing to  desire,  extension  is  provided  for.  There  are  two 
uprights,  each  carrying  a  pad  \  one  for  the  dorsal  region, 
which  should  be  large  and  take  a  good  grasp  of  the  ribs 
and  lower  part  of  the  scapula,  and  the  other  for  counter- 
pressure  in  the  lumbar  region.  These  uprights  permit 
antero-posterior  and  lateral  motion,  so  that,  as  far  as 
possible,  lateral  flexion  and  rotation  is  corrected.     There 

*  The  discussion  at  the  recent  meeting  of  the  British  Medical  Asso- 
ciation at  Belfast,  a  propos  of  Dr.  Sayre's  paper,  resulted  very  much 
in  the  repetition  of  the  opinion  I  expressed  at  the  discussion  at  the 
International  Medical  Congress  of  1 881,  viz.,  that  the  jacket  is  useless 
in  lateral  curvature,  but  valuable  in  properly  selected  cases  of  Pott's 
disease.  I  failed  to  comply  with  the  request  of  the  Secretary  of  the 
Section  to  write  out  my  speech,  hence  its  non-appearance  in  the 
Transactions. 


74 


BODILY    DEFORMITIES. 


can  be  little  doubt  that  in  the  first  and  second  stages  of 
the  disease,  these  supports,  combined  with  appropriate 
accessory  treatment,  are  very  beneficial,  and  in  many  cases 
curative  ;  and  when  the  deformity  cannot  be  quite  corrected, 
still  they  support  the  spine  and  relieve  pain,  so  that  it  not 
infrequently  happens  that  many  patients  object  to  leaving 
them  off,  and  this  I  take  to  be  a  drawback.     I  wish  it  to 


Fig.  32  — Support  for  right  dorsal  and  left  lumbar  lateral  curvatures.     The  key  is 
shown  on  the  right  of  the  figure. 


be  clearly  understood  that  I  look  upon  spinal  instruments 
only  as  valuable  adjuncts  ;  if  they  be  trusted  to  alone,  dis- 
appointment will  be  the  result,  and  if  the  pads  do  not  fit 
properly,  injurious  pressure  may  be  the  outcome.  It  must 
also  be  recollected  that  if  only  the  support  be  worn  with- 
out appropriate  gymnastics,  the  muscles  are  not  properly 
exercised,  and  the  atrophy,  which  naturally  occurs  in  sco- 
liosis, will  by  their  means  be  assisted  to  progress. 


CURVATURES    OF   THE    SPINE.  75 

I  have  had  constructed  according  to  my  directions,  by 
Mr.  Schramm,  a  light  and  effective  machine  which  appears 
to  combine  movements  in  the  various  directions  necessary  to 
facilitate  cure.  If  the  scoliotic  spine  be  sufficiently  moveable, 
either  before  or  after  the  use  of  gymnastics,  &c,  to  permit 
of  gradual  correction,  I  know  of  no  instrument  better  cal- 
culated to  effect  it ;  but  again  I  would  insist  that  even 
this,  which  I  make  bold  to  call  a  perfection,  though  not, 
perhaps,  a  perfect  instrument,  is  only  an  indispensable 
accessory  to  the  treatment. 

The  reader  will  thus  perceive  that  I  regard  spinal  sup- 
ports as  of  undoubted  importance  as  accessories ;  but  to  be 
of  service,  they  must  be  applied  with  sound  orthopaedic 
knowledge  and  surgical  discernment,  and,  moreover,  they 
must  be  constructed  on  just  mechanico-anatomical  prin- 
ciples. Those  instruments  which  act  solely  on  the  principle 
of  extension  are  useless,  those  which  act  on  the  principle 
of  uniform  pressure,  like  Sayre's  bandage,  are  worse  than 
useless  as  a  rule,  because  they  can  never  unfold  a  curve, 
and  according  to  my  experience,  and  that  of  others,  they 
even  fail  to  maintain  the  extension  of  the  spine  which  has 
been  produced  by  the  suspension  apparatus,  and,  moreover, 
perseverance  in  their  use  loses  valuable  time.  Inclination 
and  flexion  machines  like  those  of  Hossard  and  Guerin  do 
not  fulfil  the  indications.  The  former  act  on  the  principle 
which  appears  theoretically  good,  viz.,  to  incline  the  trunk 
from  the  side  to  which  it  naturally  tends  in  the  disease,  and 
by  pressing  on  the  greatest  point  of  curvature,  to  force  that 
part  of  the  spine  situated  above  it  to  become  corrected ; 
but  experience  proves  that  it  is  only  of  any  value  in  the 
milder  cases,  and  that  if  applied  to  well  marked  curves,  the 
pelvic  support  shifts,  and  it  is  necessary  to  fix  it  by  a 
perineal  band  which,  at  best,  is  irksome.  The  best  instru- 
ments are  those  which  combine  extension  and  pressure  in 


J 6  BODILY    DEFORMITIES. 

the  anteroposterior,  lateral  and  oblique  directions,  but  it 
must  not  be  forgotten  that  if  the  scoliosis  be  due  to 
rachitis  either  infantile  or  adolescentium,  the  ribs  may  be 
affected,  and  that  pressure  will  only  further  deform  the  ribs 
without  correcting  the  mal-placed  spine. 

Spinal  Tenotomy  or  Myotomy.— Gue'rin  first  intro- 
duced this  method,  and  claimed  many  successes,  but  it  was 
found  on  examining  the  cases  sometime  subsequently,  that 
they  had  relapsed,  or  rather,  had  been  made  worse  by  the 
operation.  Sayre  has  divided  the  latissimus  dorsi,  and 
was  satisfied  with  the  result.  My  own  view  of  these 
operations  is  that,  as  a  rule,  they  are  valueless  and  may  be 
harmful,  but  that  in  rare  exceptional  cases,  division  of  the 
contracted  latissimus  dorsi  may  be  of  service. 

Forcible  rectification  under  Anaesthesia.— I  have, 
as  yet,  no  personal  experience  of  this  plan,  and  should 
think  that  but  few  cases  are  suitable  to  it.  However,  it 
seems  to  me  a  plan  worthy  of  trial,  and  when  I  get  a  case 
that  appears  to  me  a  proper  one,  I  shall,  carefully,  adopt  it. 
Of  course,  in  any  proceeding  of  this  kind,  great  caution 
would  be  necessary  to  avoid  serious  injury  to  the  spinal 
column  and  its  contents. 

Summary  of  Treatment. — It  will  have  been  observed 
that  I  believe  in  the  curability  of  lateral  curvature  in  the 
early  stage,  and  in  its  amelioration  in  more  advanced 
degrees,  and  that  I  consider  the  best  means  to  these 
desirable  ends  to  be  of  an  eclectic  nature.  No  one  form  of 
treatment,  whether  mechanical,  gymnastic,  or  other,  is 
alone  of  avail  in  the  majority  of  cases.  Each  case  must 
be  treated  on  its  merits,  with  due  consideration  of  its  cause, 
the  general  condition  of  the  patient,  the  stage  of  the 
deformity,  the  mobility  of  the  spine  in  its  affected  part, 
and  in  young  women  the  state  of  the  uterine  functions. 
There  is  no  panacea  for  lateral  curvature,  and  only  a  large 


CURVATURES    OF   THE    SPINE.  77 

experience,  combined  with  a  knowledge  of  the  pathology 
of  the  disease — so  far  as  it  goes — are  the  safest  guides. 

Rest,  if  there  be  pain  or  discomfort  in  the  erect  position  ; 
gymnastics,  especially  local ;  massage  applied  by  the  sur- 
geon or  by  some  one  knowing  the  elements  of  anatomy 
and  physiology ;  electricity  in  suitable  cases ;  tonics,  &c, 
as  previously  described,  are  each  and  all  of  undoubted 
benefit,  but  it  is  scarcely  possible  to  indicate  accurately  the 
limits  of  these,  and  to  point  out  which  cases  are  suitable  and 
which  not.  This  must  be  left  to  experience,  and  speaking 
from  an  exceptionally  large  one  in  orthopaedics,  and  having 
in  mind  cases — not  a  few — which  have,  to  all  external 
appearances,  become  cured,  while  the  general  health  has 
coincidently  improved,  I  have  confidence  in  recommend- 
ing the  combined  mode  of  treatment  which  I  have  described. 


78  BODILY    DEFORMITIES. 


CHAPTER   V. 

DEFORMITIES    OF   THE   THORAX. 

Pigeon-breast. 

These  are  generally  secondary  to  disease  of  the  spine,  or 
to  thoracic  inflammation,  or  new  growths,  or  due  to  rickets. 
A  common  form  of  chest  distortion  caused  by  rickets, 
though  sometimes  independent  of  it,  is  pigeon-breast. 

Synonyms. — Latin,  Pectus  carinatum  seu  gallinatum  ; 
German,  Hiihner  oder  Kahnbrust. 

Varieties  and  Causes. — It  may  be  jbrhnary  or  secon- 
dary. The  former  is  due  to  bone-softening,  through  local 
or  general  rickets  or  mollifies.  The  latter  is  acquired  and 
caused  by  scoliosis,  kyphosis,  lordosis,  paralysis  of  the 
intercostals  (after  whooping-cough  for  instance),  and 
pleurisy.  It  may  be  congenital  as  a  result  of  pulmonary 
atalectasis.  Sometimes  this  condition  is  hereditary  and 
none  of  the  above  causes  give  evidence  of  their  existence. 

Symptoms. — Objectively  the  ribs  are  flattened  at  the 
sides,  the  lower  part  of  the  stomach  projects,  and  the 
lower  costal  cartilages  are  deformed.  The  transverse 
diameter  of  the  chest  is  diminished,  and  its  antero-posterior 
increased,  at  the  deviated  part.  Subjectively  the  patient 
complains  of  shortness  of  breath,  and,  in  the  severe  forms, 
of  palpitation.  As  the  patients  reach  mid-life,  bronchitis 
and  emphysema  are  common. 

Pathogenesis. — Some  cases  seem  to  be  due  to  general 


DEFORMITIES    OF   THE   THORAX.  79 

debility  and  to  atonicity,  especially  of  the  respiratory 
muscles,  which  not  acting  sufficiently  in  raising  and  evert- 
ing the  ribs,  these  become  flattened,  and  then  the  cartilages 
bend,  and  the  sternum  projects. 

In  the  rachitic  cases  the  view  of  Sir  W.  Jenner  is  that 
now  accepted,  and  this  is  that  the  glottic  aperture  is  not 
large  enough  to  permit  of  air  entering  with  sufficient  rapidity 
to  occupy  the  increased  space  formed  in  the  thorax  by 
diaphragmatic  action,  and  consequently  the  effects  of 
atmospheric  pressure  are  expressed  on  the  chest-walls, 
the  ribs  are  sharply  bent  at  their  angles,  and  the  costal 
cartilages  turn  abruptly  backwards  at  the  costo-cartilaginous 
junctions,  and  the  sternum  projects  forwards.  In  such 
cases  there  is  a  groove  along  the  line  of  union  of  the  ribs 
and  cartilages,  just  behind  the  nodules  or  beads  which  are 
formed  at  these  spots.  The  pressure  of  the  arms  on  the 
sides  of  the  chest  also  tends  to  produce  pigeon-breast  when 
the  bones  are  soft. 

Prognosis. — If  the  spinal  deformity  can  be  cured  or 
improved,  the  thoracic  change  will  ameliorate.  Rachitic 
cases,  especially  if  due  to  the  acute  or  severe  form  o. 
general  rickets,  are  much  less  hopeful,  but  even  these  are 
not  absolutely  hopeless.  The  paralytic  form  is  generally 
curable,  and  the  cyphotic  form  is  very  amenable  to  treat- 
ment. 

Treatment. — This  must  be  directed  to  the  cause,  and 
if  this  can  be  satisfactorily  acted  on,  much  may  be  hoped. 
The  rachitic  cases  require  the  treatment  spoken  of  in  the 
chapter  on  Rickets ;  the  paralytic  need  massage,  electricity, 
and  respiratory  exercises,  and  these  are  also  very  service- 
able in  those  cases  secondary  to  spinal  curvature.  In  these 
latter  cases,  the  curvature  and  its  cause  must  be  attacked, 
and  local  gymnastics  combined  with  the  other  means  just 
mentioned,  are  of  great  service. 


8o  BODILY    DEFORMITIES. 


CHAPTER    VI. 

DEFORMITIES    OF    THE    ABDOMEN. 

Pendulous  Abdomen  is  a  common  and  unsightly 
condition,  especially  in  women,  and  may  be  due  to  general 
or  local  causes.  Obesity  is  the  commonest  among  the 
former,  and  among  the  latter  are  local  polysarcia  and  um- 
bilical and  ventral  herniae. 

Symptoms. — The  objective  symptoms  are  sufficiently 
obvious.  The  patient's  complaints  refer  chiefly  to  weight 
and  dragging  from  the  size  of  the  tumour,  and  if  this  be  a 
rupture,  the  sensation  is  usually  referred  to  the  navel  or  the 
upper  lumbar  spine.  There  is  usually  difficulty  in  walking 
or  standing,  due  to  discomfort  from  the  weight  of  the 
tumour,  and  shortness  of  breath,  which  is  probably  due  to 
general  corpulence. 

Diagnosis. — Ascites,  tumours  of  the  abdominal  wall,  a 
much-enlarged  liver,  ovarian  and  abdominal  tumours,  preg- 
nancy, and  lordotic  abdomen,  may  occasion  difficulty  to 
the  inexperienced,  but  the  real  differential  diagnosis  lies 
between  extra-abdominal  tumour,  umbilical  or  ventral 
hernia,  and  local  polysarcia.  The  fact  that  in  these  the 
protuberance  can  generally  be  made  out  to  be  chiefly  out- 
side the  abdominal  wall,  and  that  in  local  over-production 
of  fat,  distinct  creases,  often  with  eczema  in  the  folds,  are 
present,  will  assist,  and  with  the  history  of  the  case  will,  in 
most  cases,  clear  up  the  diagnosis. 


DEFORMITIES    OF   THE   ABDOMEN.  8 1 

Treatment. — In  polysarcia  local  compression  by  means 
of  a  properly  fitting  belt  is  of  service,  combined  with  a 
correct  diet  and  regimen  for  corpulence.  In  extra-abdom- 
inal tumours  excision  is  the  remedy,  especially  as  these 
growths  are  generally  innocent.  There  is  risk,  however, 
from  peritonitis,  as  most  of  these  growths  are  attached 
beneath  the  transversalis  fascia,  and  sometimes  they  have 
to  be  separated  from  the  peritoneum,  as  was  the  case  in  a 
large  growth  with  a  vascular  capsule  which  I  removed  from 
a  patient  in  the  hospital  for  women.  In  hernia,  unless 
there  be  symptoms  calling  for  operative  interference,  the 
treatment  should  be  directed  to  supporting  the  rupture  and 
preventing  further  protrusion.     When  operation  is  neces- 


Fig.  33. — For  pendulous  abdomen. 

sary,  a  free  incision  should  be  made  carefully  over  the 
tumour,  prolapsed  omentum  should  be  tied  in  pieces  and 
removed,  the  bowel  returned,  and  the  peritoneal  surfaces 
brought  well  together.  It  is  well,  in  some  cases,  to  remove 
a  portion  of  the  thinned  and  stretched  skin,  so  as  by  the 
cicatrix — which  should  subsequently  be  well  supported  by 
a  proper  belt — to  still  further  contract  the  abdominal 
cavity. 

I  operated  on  two  umbilical  and  one  ventral  hernia  (one 
male  and  two  females)  some  years  ago  in  this  manner,  and 
the  patients  and  I  were  well  pleased  with  the  results.  A 
middle-aged  woman  was  under  my  care  in  Locock  ward  of 

G 


82 


BODILY    DEFORMITIES. 


the  Hospital  for  Women,  sadly  inconvenienced  by  an 
enormous  hernia  through  the  lineaalba,  which,  on  standing, 
reached  nearly  to  her  knees.  I  proposed,  without  specially 
urging,  abdominal  section,  which,  at  one  time,  she  seemed 


Figs.  34  and  35.— Protuberant  and  pendulous  abdomen  before  and  after  application 

of  a  proper  corset. 


inclined  to  undergo,  but  subsequently  an  abdominal  belt 
was  constructed  which  enabled  her  to  once  more  get  about 
her  domestic  duties  with  comparative  comfort. 


83 


CHAPTER  VII. 

TORTICOLLIS    OR   WRY-NECK. 

Definitions. — Wry-neck  is  a  deformity  characterised  by 
lateral  inclination  and  rotation  of  the  head.  The  simpler 
forms  of  torticollis  are  devoid  of  rotation,  and  are  not 
usually  described  under  this  heading.  I  take  up  this  sub- 
ject after  that  of  scoliosis,  because  the  pathological  condi- 
tions of  flexion  and  rotation  of  the  cervical  spine,  exist  in 
well  marked  cases  of  this  deformity,  though  they  are 
usually  produced  by  muscular  action  only. 

Synonyms. — Latin,  Caput  obstipum,  Torticollis ;  Ger- 
man, Halsteifheit  Schiefhals ;  French,  Torticolis,  Con  tortu. 

Varieties  and  Causes. — Wry-neck  may  be  congenital  ox 
acquired.  It  may  also  be  acute  or  chronic ;  the  former  is 
usually  symptomatic  of  an  inflammation  of  the  cervical 
muscles  or  fascia  which  is  either  due  to  cold,  rheumatism, 
inflammation,  or  injury;  the  latter  may  be  caused  by 
muscular  spasm  or  contraction,  or  by  paralysis  ;  or  it  may 
be  due  to  the  condition  of  the  bones,  vertebral  articula- 
tions, to  burn- cicatrices,  or  to  disease  of  the  nervous 
system.  Cervical  tumours  may  also  give  rise  to  it,  as  may 
also  caries  of  the  cervical  spine,  and  dislocations  and 
fractures.  This  malady  may  be  permanent,  intermittent, 
spasmodic,  symptomatic,  or  essential ;  and  these  terms  suffi- 
ciently explain  themselves.     It  may  vary  in  degree,  being 

G    2 


84 


BODILY    DEFORMITIES. 


like  other  maladies,  slight,  moderate  or  extreme.  It  may- 
be simulated  by  hysteria  and  by  malingerers.  It  is  occa- 
sionally hereditary.  The  congenital  form  may  be  due  to 
nerve  lesions  or  deformities,  or  to  deformed  vertebral 
articulations,   or  to  intra-uterine  malposition,  or  obstetric 


\ 


Fig.  36. — Congenital  muscular  torticollis  in  a  boy  aged  ten. 


injuries.     The  acquired  forms  are  usually  due  to  the  other 
causes  stated  in  this  paragraph. 

Traumatic  Torticollis  may  be  due  to  partial  or  com- 
plete luxation  of  the  cervical  vertebrse,  or  to  rupture  of 
some  of  the  cervical  muscles,  and  sometimes,  in  infants,  it 


TORTICOLLIS    OR    WRY-NECK.  85 

is  congenital  in  the  sense  that  the  sterno-mastoid  alone,  or 
other  cervical  muscles  are  torn  during  birth,  or  compressed 
by  the  forceps,  and  paralysed.  There  is  also  a  form  of 
wry-neck  in  infants  due  to  a  tumour-thickening  of  the 
sterno-mastoid,  the  exact  nature  of  which  has  not  yet  been 
made  out.  I  have  seen  many  examples  of  all  forms,  and 
not  a  few  cases  of  wry-neck  due  to  injury  to  the  cervical 
spine  or  cervical  muscles,  have  come  under  my  notice  at 


Fig.  37. — Cicatricial  torticollis  following  a  burn. 

the  London  Hospital.  The  ordinary  forms  of  torticollis 
which  come  under  the  care  of  the  Orthopaedic  Surgeon,  are 
those  due  to  lesions  of  the  muscular  or  nervous  systems  ; 
the  former  are  the  commoner ;  that  is  to  say,  whether  the 
primary  mischief  be  in  the  nervous  system  or  in  the 
muscles,  some  of  the  latter  are  always  found  contracted 
when  the  cases  come  under  care,  and  are  corrected  by  teno- 
tomy, an  appropriate  apparatus  and  gymnastics.  The  sterno- 
mastoid  appears  to  be  the  chief  muscle  in  the  production 


86  BODILY   DEFORMITIES. 

of  the  deformity,  but  others  may  also  be  affected,  so  that 
any,  or  all  of  the  muscles  which  produce  flexion  and  rotation 
of  the  head  may  give  rise  to  it.  I  have  seen  cases  due 
chiefly  to  the  action  of  the  trapezius,  the  splenius,  the 
scalenes  and  other  muscles,  and  in  such  cases  the  deviation 
of  the  head  is  different;  and  Duchenne  has  described  a 
case  in  which  the  deformity  was  due  to  the  combined  action 


Fig.  38. — Spastic  muscular  torticollis  in  a  girl  aged  ten. 

of  the  splenius  and  anterior  scalene.     Typical  torticollis  is, 
however,  caused  by  the  action  of  the  sterno-mastoid. 

Torticollis  due  to  contraction  or  shortening  of 
the  sterno-mastoid.— It  will  be  well  briefly  to  consider 
the  action  of  this  muscle.  Some  anatomists  regard  each 
sterno-mastoid  as  composed  of  two  and  even  more  muscles, 
but  all  agree  that  in  contracting,  it  inclines  the  head  to  its 
own  side,  and  causes  it  to  rotate  so  that  the  face  is  directed 
to  the  opposite  side ;  this  is  when  it  takes  its  fixed  point 
below,  but  if  the  fixed  point  be  at  the  mastoid  process,  it 


TORTICOLLIS    OR    WRY-NECK.  87 

acts  as  an  inspiratory  muscle.  It  is  supplied  by  the  spinal 
accessory  nerve  and  cervical  plexus,  and  Sir  Charles  Bell 
considered  its  cervical  nerves  as  making  it  a  muscle  of  re- 
lation, while  the  spinal  accessory  caused  it  to  contract  in 
an  involuntary  manner  during  respiration.  Claude  Bernard 
considered  that  the  spinal  accessory  had  nothing  to  do  with 
simple  respiration,  but  was  only  brought  into  play  during 
respiratory  efforts,  as  in  ordinary  singing  or  in  dyspnoea. 
Haller  thought  that  the  sternal  portion  of  the  muscle  pro- 
duced cranial  rotation,  and  that  the  clavicular  part  caused 
depression  towards  the  corresponding  shoulder.  J.  Gue'rin 
considered  that  the  sternal  part  was  rather  a  mover  of  the 
head  than  a  respiratory  muscle,  and  that  the  clavicular  part 
was  essentially  inspiratory.  Modern  Anatomists  are  pretty 
well  agreed  as  to  its  actions  of  flexion  and  rotation  of  the 
head,  and  I  think  there  can  be  little  doubt  as  to  its  being, 
at  any  rate,  an  extraordinary  muscle  of  inspiration ;  but  of 
this  there  can  be  no  question  that  contraction,  retraction, 
or  paralysis  of  one  sterno-mastoid,  from  whatever  cause, 
will  induce  wry-neck. 

It  may  be  well  to  define  these  terms.  By  contraction  is 
meant  that  condition  of  a  muscle  in  which  it  is  largely 
beyond  voluntary  control,  and  the  fibres  of  which  are  in  a 
permanent  state  of  shortening,  without,  however,  showing 
microscopic  changes.  This  state  ceases  under  anaesthesia, 
and  it  appears  that  it  is  due  primarily  to  some  altered  con- 
dition of  the  nervous  system,  but  if  contraction  be  suffi- 
ciently prolonged,  it  must  pass  into  retraction.  Retraction 
results  from  a  muscle  being  constantly  involuntarily 
shortened,  and  a  portion  of  such  muscle  shows,  micros- 
copically, atrophy  and  fatty-degeneration.  It  persists  dur- 
ing anaesthesia,  unless  the  degenerated  muscle  be  torn,  and 
may  be  the  result  of  nerve  lesion  or  of  injury  or  inflamma- 
tion of  the  muscle  itself  or  its  sheath.     If  a  muscle  be 


88 


BODILY    DEFORMITIES. 


paralysed,  it  may  not  only  undergo  fatty  degeneration,  but 
its  opponents  may,  and  often  do  in  time,  contract,  and  its 
two  ends  becoming  approximated  will  gradually  lead  to 
retraction,  so  that  in  paralytic  torticollis  there  may  at  first 
be  clonic  spasms  of  the  opposite  sterno-mastoid  leading 
finally  to  its  contraction  and  retraction. 


Fig.  39.—  Posterior  view  of  a  case  of  muscular  torticollis,  showing  the  curve  of  the 
cervical  spine  and  the  altered  levels  of  the  shoulders  and  scapulae. 


Wry-neck  is  almost  twice  as  common  on  the  right  as  on 
the  left  side,  and  is,  in  my  experience,  commoner  in  females 
than  males.  The  congenital  forms  are  rare  and  may  be 
temporary,  intermittent,  or  permanent,  of  which  the  latter 
is,  if  I  may  use  the  expression  in  these  rare  cases,  the 
commonest,  and  the  symptoms  of  this,  and  the  acquired 
forms,  are  very  similar,  except  that  in  infants  with  fat,  short 
necks,  the  prominence  of  the  lower  part  of  the  sterno- 
mastoid  is  not  so  evident. 


TORTICOLLIS    OR    WRY-NECK.  89 

Spasmodic  or  Intermittent  Torticollis. — In  this 
condition  the  head  is  not  involuntarily  and  immovably 
fixed  in  one  position,  but  the  patient,  in  some  cases,  has  the 
power  of  correcting  the  deformity,  while  in  other  cases  the 
spasm  is  chronic  and  interrupted,  and  the  symptom  appears 
due  to  neurotic  local  convulsions.  Other  cases  are  con- 
sidered by  Duchenne  and  some  nerve  pathologists  to  be 
due  to  functional  spasm,  and  such  instances  are  character- 
ised by  continuous  and  painful  or  indolent  contraction,  or 
by  chronic  contraction  and  tremors,  especially  if  the  muscles 
be  voluntarily  brought  into  play ;  in  fact,  they  are  similar  to 
functional  spasms  in  other  regions,  a  familiar  instance  of 
which  is  stuttering,  which,  as  is  well  known,  is  aggravated 
by  volition  and  mental  excitement.  The  nature '  of  the 
lesion,  which  is  probably  in  the  nervous  centres,  has  not  yet 
been  determined.  In  these  cases  the  wry-neck  is  apparent 
when  the  patient  is  standing,  but  disappears  on  lying  down. 
Duchenne  relates  the  case  of  a  man  at  sixty  whose  sterno- 
mastoids,  while  standing  or  sitting,  contracted  strongly,  and 
forcibly  flexed  his  chin  against  his  chest,  but  when  he 
threw  his  head  back,  the  contractions  at  once  ceased,  and 
returned  directly  he  attempted  to  bring  it  forward.  Not 
long  since  I  treated  a  case  at  the  London  Hospital  which 
was  under  the  care  of  Dr.  Jackson.  He  was  a  man  of 
middle  age  with  convulsive  postero-lateral  jactitation,  as  I 
called  it,  i.e.,  his  head  was  thrown  chiefly  backwards  and 
sometimes  with  rotation  to  one  or  the  other  side,  and  this 
condition  largely  disappeared  when  he  was  lying  down  or 
when  asleep,  but  on  standing  it  returned,  and  especially 
when  attention  was  drawn  to  him.  It  was  not  a  question 
of  malingering,  and  I  first  stretched,  and  then  excised  a 
portion  of  each  spinal  accessory  nerve,  with,  however,  only 
temporary  benefit,  as  the  disease  was  probably  high  up  in 
the  cord.     We  once  thought  of  dissecting  out  and  stretch- 


90  EODILY    DEFORMITIES. 

ing  the  cords  of  the  brachial  plexus,  but  on  reconsideration, 
this  idea  was  abandoned.  I  believe  that  the  convulsive 
attacks  returned,  though,  perhaps,  in  not  so  severe  a  degree. 
There  is  a  form  of  rotatory  torticollis  in  which  the  head 
executes  a  series  of  movements  of  lateral  flexion  and  rota- 
tion, and  sometimes  these  are  regular  and  continuous,  but 
more  commonly  they  are  spasmodic,  though  often  rhyth- 
mical. This  is  a  chronic  affection  and  difficult  of  treat- 
ment. Its  cause  seems  to  reside  in  the  nerve  centres,  and 
the  sterno-mastoid  alone,  or  associated  with  the  trapezius 
and  splenius,  are  commonly  the  muscles  affected. 

Paralytic  Wry-neck.— This  may  be  due  to  a  central 
nerve  lesion,  or  to  mischief  or  injury  in  the  course  of  the 
nerves  supplying  the  cervical  muscles.  If  one  sterno- 
mastoid  be  paralysed,  the  other  contracts  and  produces  the 
deformity,  and  the  secondary  changes  due  to  approximation 
of  its  attachments  result,  so  that  it  is  often  necessary  to 
divide  both  heads  of  the  contracted  muscle  before  the 
deformity  can  be  reduced.  In  infants  it  has  been  produced 
by  obstetric  injury  or  manipulation. 

Wry-neck  produced  by  other  cervical  muscles  — 
When  the  clavicular  portion  of  the  trapezius  assists  the 
sterno-mastoid  in  producing  the  deformity,  its  anterior 
border  is  prominent,  and  the  head  is  more  inclined  to  one 
side  and  thrown  somewhat  backwards.  If  it  be  recollected 
that  the  external  branch  of  the  spinal  accessory  supplies 
both  muscles  (at  any  rate  in  part)  their  conjunction  in  pro- 
ducing many  cases  of  this  deformity  is  only  what  one  would 
expect.  Sometimes  the  levator  anguli  scapulae,  the  splenius 
and  anterior  scalenes  may  singly,  or  together,  act  in  concert 
with  the  sterno-mastoid  of  the  opposite  side,  and  we  may 
thus  get  various  positions  of  the  head,  which,  in  the  case 
of  the  splenius  or  scalenes  of  one  side  acting  with  the 
sterno-mastoid  of  the  opposite,  would  cause  extension  and 


TORTICOLLIS    OR   WRY-NECK. 


91 


extreme  rotation  of  the  cervical  spine,  whereas  the  levator 
of  one  side  acting  with  the  sterno-mastoid  of  the  opposite, 
would  cause  increased  lateral  flexion  and  rotation. 

Gooch  relates  a  case  of  wry-neck  due  to  contraction  of 
one  platysma,  and  in  this  case  the  corresponding  labial 
commissure  was  much  depressed.     Dieffenbach  records  an 


Fig.  40. — Wry-neck  from  nervous  diseases  in  a  girl  aged  twelve.  There  was 
spastic  contraction  of  the  sterno-mastoid  and  deeper  cervical  muscles,  and  a  para- 
lytic wasting  of  the  muscles  of  the  left  side.  The  left  scapula  was  less  developed 
and  much  more  drawn  up  than  the  right.    When  an  infant  she  had  infantile  paralysis. 


instance  in  which  both  these  muscles  were  contracted,  the 
head  being  directly  drawn  downwards.  If  only  a  part  of 
this  muscle  be  contracted,  the  position  of  the  head  will  vary 
according  to  the  part  of  the  muscle  affected.  When  the 
platysma  is  much  contracted,  the  grooves  in  the  skin  are 
strongly  pronounced. 


92  BODILY    DEFORMITIES. 

Age,  sex,  and  side  of  the  disease.— In  my  experience, 
which  I  believe  agrees  with  that  of  most  orthopaedic 
surgeons,  this  affection  is  commonest  in  young  people.  I 
have  also  met  with  it  more  frequently  in  females,  and  the 
majority  of  my  cases  have  been  on  the  right  side.  Some- 
times the  head  is  inclined  towards  the  shoulder  of  the 
same  side  on  which  the  muscle  is  contracted,  and  the  face 
is  turned  to  the  opposite  side.  The  amount  of  inclination 
and  rotation  will  vary  according  to  the  extent  of  the 
deformity.  In  the  severe  cases  the  shoulder  and  ear 
may  touch,  the  skin  will  be  puckered  on  the  concave  side, 
and  tense  on  the  convex.  The  chin  will  be  turned  towards 
the  shoulder  opposite  to  the  muscle  producing  the  deformity, 
which  latter  will  be  found  prominent  and  tense,  according 
to  the  degree  of  contraction  or  retraction  which  has 
occurred.  It  is  generally  smaller  because  of  the  fibrous 
degeneration  which  it  has  undergone. 

Symptoms. — These  have  been  partly  given  in  the  pre- 
ceding paragraphs.  The  deformity  is  obvious.  The  con- 
tracted muscle  is  not  usually  painful  when  at  rest,  though 
it  may  become  so  when  the  deformity  is  attempted  to  be 
corrected  by  the  surgeon's  hands.  Voluntary  motion 
to  rectify  the  deformity  is  entirely,  or  almost  completely 
abolished,  though  the  patient  can  often  increase  the 
deformity.  In  many  cases  passive  movements,  without 
anaesthetics,  produce  little  effect,  though  the  tension  and 
prominence  of  the  muscle  may  be  thereby  increased. 
The  temperature  on  the  contracted  side  is  slightly  higher 
than  that  of  the  opposite  side.  In  cases  of  long  standing, 
the  cervical  spine  becomes  affected  so  that  the  spinous 
processes  of  the  upper  and  middle  cervical  vertebrae  form 
a  curve,  the  convexity  of  which  is  usually,  in  my  experience, 
on  the  opposite  side  to  the  deformity,  though  sometimes 
it  may  be  on  the  same  side,  and  if  the  case  be  an  old  one 


TORTICOLLIS    OR    WRY-NECK.  93 

or  congenital,  and  has  lasted  for  some  time,  secondary 
curves  are  formed  in  the  dorsal  and  lumbar  regions,  and  the 
concavity  of  these  curves  will  be  in  an  opposite  direction 
to  that  of  the  curve  immediately  above. 

In  old-standing  cases,  the  face  and  head  on  the  side 
affected  are  deficiently  developed,  the  angle  of  the  mouth 
and  the  eye  on  the  side  affected,  are  drawn  down,  so  that 
in  some  cases  double  vision  results,  the  opposite  cheek 
appears  stretched  and  that  side  of  the  face  more  prominent. 
In  severer  cases  the  functions  of  the  larynx  are  interfered 
with,  the  side  of  the  head  corresponding  to  the  deformity 
is  more  or  less  atrophied,  while  the  opposite  appears,  in 
consequence,  larger  than  normal ;  and  it  has  been  shown 
that  this  condition  is  associated  with  a  defective  develop- 
ment of  the  corresponding  cerebral  hemisphere,  causing  a 
relative  inferiority  of  the  muscles  of  the  opposite  side. 
Bouvier  found  in  a  post-mortem  which  he  made,  that  the 
carotid  on  the  deformed  side,  was  much  smaller  than  that 
on  the  opposite  ;  and  this,  he  thought,  accounted  for  these 
abnormalities  of  development. 

Pathology.— But  little  is  known  of  the  primary  con- 
ditions leading  to  the  deformity,  except  that  there  is  some 
source  of  irritation,  and  possibly  a  sclerosis  about  the  seat 
of  origin,  or  in  the  course  of  the  fibres  of  the  nerves 
supplying  the  cervical  muscles,  but  the  seco?idary  changes 
produced  by  the  deformity  have  been  ascertained  in  a  very 
few  cases.  In  these  the  muscles  have  been  found  de- 
generated, the  ligaments  shortened  on  the  affected  side,  the. 
vertebrae  compressed  on  the  same  side,  and  the  articula- 
tions partially  or  completely  destroyed.  But  in  other  cases 
of  several  years'  standing,  only  a  slight  diminution  of  the 
height  of  the  vertebrae,  and  corresponding  vertebral  sub- 
stances was  observed. 

With  reference  to  the   question  whether   one   or  both 


94  BODILY   DEFORMITIES. 

origins  of  the  sterno-mastoid  are  implicated  in  the  disease, 
there  seems  to  be  no  hard  and  fast  rule,  though  I  have 
generally  found  that  if  the  sternal  portion,  which  is  almost 
always  involved,  has  been  divided,  the  clavicular  becomes 
prominent ;  so  that  if  at  the  origin  of  the  malady,  the  sternal 
portion  is  first  affected,  later  on  the  clavicular  part  becomes 
implicated  by  the  position  assumed.  I  would  say  that  in 
rather  more  than  half  of  the  cases  when  first  seen,  both 
portions  are  affected  ;  and  that  of  the  remaining  half,  the 
sternal  portion  is  contracted  three  or  four  times  more 
frequently  than  the  clavicular  portion. 

Diagnosis-— Wry-neck  due  to  nervo-muscular  contraction 
is  usually  easy  to  diagnose  from  those  cases  of  torticollis 
due  to  mal  -  position,  or  to  cervical  inflammation, 
whether  of  the  bones,  articulations  or  fascia,  and  from 
wry-neck  due  to  the  presence  of  a  tumour ;  but  the 
differential  diagnosis  between  a  purely  sterno-mastoid 
torticollis,  and  one  in  which  other  muscles  are  con- 
cerned, is  not  so  easy.  If  the  position  of  the  head  and 
of  the  neck,  the  prominence  and  rigidity  of  the  various 
muscles,  and  the  actions  they  normally  produce,  be  all 
taken  into  consideration,  one  may  arrive  at  a  pretty  accurate 
estimate  of  the  muscles  involved.  The  action  of  the 
sterno-mastoid  has  been  sufficiently  spoken  of,  but  it 
should  be  recollected  that  the  upper  part  of  the  trapezius 
acting  from  below,  inclines  the  head  to  its  own  side,  while 
it  slightly  extends  it,  and  turns  the  face  to  the  opposite 
side.  The  anterior  and  posterior  scalenes,  acting  from 
below,  flex  the  neck  and  incline  the  head  to  the  same  side. 
The  splenius  extends  the  head,  inclines  it  to  its  own  side, 
and  causes  it  to  rotate  the  face  towards  its  own  side.  The 
complexus  extends  the  head  and  turns  it  to  the  opposite 
side  ;  the  levator  scapulas,  acting  from  above,  inclines  the 
head  backwards  and  to  its  own  side.     The  platysma  also 


TORTICOLLIS    OR   WRY-NECK.  95 

turns  the  head  to  its  own  side  ;  so  that  three  muscles  in 
whole  or  part,  turn  the  head  to  the  opposite  side,  viz.,  the 
sterno-mastoid,  the  trapezius,  and  the  complexus,  whereas 
five  draw  the  head  towards  their  own  side,  viz.,  the  scalenes, 
the  splenius,  the  levator  anguli  scapulae  and  the  platysma. 
Paralytic  cases  in  which  the  opposite  muscle  is  contracted 
and  retracted  will  only  offer  difficulty  until  a  clear  history 
be  obtained.  In  these  cases  the  patient  cannot  move  the 
head  in  the  least,  nor  produce  any  prominence  of  the 
muscles  on  the  paralyzed  side,  and  the  surgeon  can  easily 
correct  the  deformity,  meeting  usually  with  next  to  no 
resistance ;  but  if  the  case  be  of  long  standing,  the  opposite 
muscles  will  have  become  strongly  retracted,  and  will  offer 
obstacles  to  manipulation.  In  these  cases,  as  in  others, 
anesthesia  will  clear  up  the  question  as  to  whether  the 
muscle  be  simply  contracted,  or  retracted,  as  in  the 
former  case  the  deformity  can  be  rectified,  whereas  in  the 
latter  it  can  only  be  reduced  by  rupturing  the  muscle.  The 
hysterical  and  malingering  forms  of  the  disease  are  best 
diagnosed  under  an  anaesthetic. 

Prognosis. — Although  this  deformity,  whatever  may  be 
its  cause,  almost  never  leads  to  death,  still  it  may,  as 
already  pointed  out,  occasion  serious  disabilities,  and  so 
interfere  with  the  important  movements  of  the  head,  and 
of  the  functions  of  the  organs  therein  placed,  that  life  is 
scarcely  bearable.  But  fortunately  the  permanent,  as  con- 
tra-distinguished from  the  spasmodic  forms,  are  amenable  to 
surgical  treatment,  and  not  only  may  the  deformity  be  recti- 
fied but  the  patient  return  to  health  in  a  happy  frame  of 
mind. 

Treatment. — This  must  naturally  depend  upon  the 
cause  producing  the  deformity.  If  it  be  due  to  cold, 
injury,  or  rheumatism,  appropriate  remedies  must  be 
applied ;  if  due  to  a  syphilitic  or  gouty  myositis  the  treat- 


g6  BODILY    DEFORMITIES. 

ment  for  these  affections  must  be  instituted.  In  the  case 
of  paralysis,  frictions,  massage,  electricity  by  the  interrupted 
or  continuous  current,  nux  vomica  and  strychnine  may  all 
be  judiciously  employed,  and  if  these  means  fail,  a  well 
padded  collar  or  head-supporter  must  be  worn.  If  the 
opposite  muscle  be  retracted,  its  tendon  must  be  divided, 
and  the  subsequent  treatment  must  be  that  of  other  forms 
of  torticollis  about  to  be  described.  In  recent  years,  sub- 
cutaneous injections  of  atropine  over  the  muscle,  and  the 
ether-spray  along  its  course,  have  been  recommended, 
though  I  know  of  no  cases  in  which  they  have  sufficed  for 
cure. 

In  cases  where  the  muscles  are  contracted,  or  even 
retracted,  rectification  under  anaesthesia,  with  immediate  fixa- 
tion of  the  head  in  an  apparatus,  may  be  tried  ;  tenotomy, 
however,  offers  the  best  resource  in  the  latter  case,  but  in 
the  former,  massage,  electricity,  and  education  of  the  neck- 
muscles  by  passive  and  active  exercises,  and  by  wearing  a 
properly  adjusted  collar,  should  always  have  fair  trial.  In 
the  majority  of  permanent  cases  tenotomy  becomes  neces- 
sary, and  in  acquired  cases  there  can  be  no  question  but 
that  when  the  muscle  is  retracted,  and  the  deformity  pro- 
nounced, this  is  the  proper  course ;  but  in  congenital  cases 
one  should,  as  a  rule,  wait  till  the  child  is  from  one  to  two 
years  old,  so  that  the  neck  may  become  more  developed, 
and  the  tendon  and  its  relations  be  more  clearly  made  out 
before  tenotomy  be  done.  As  to  whether  one  or  both 
origins  of  the  muscle  should  be  divided  at  the  same  time, 
opinions  have  been  divided,  but  one  must  be  guided  by 
the  condition  of  the  clavicular  portion  after  the  sternal 
part  has  been  cut.  According  to  my  experience,  and  that 
of  the  majority  of  orthopaedic  surgeons,  both  tendons  will 
have  to  be  divided  more  frequently  than  not,  especially  in 
adolescents  and  adults. 


TORTICOLLIS    OR    WRY-NECK. 


97 


Tenotomy. — The  best  place  to  divide  the  muscle  is  at  its 
ower  part,  because  at  its  upper  it  is  more  or  less  surrounded 
with  nerve  filaments,  and  is  pierced  at  a  varying  distance  by 
the  spinal  accessory,  and  if  the  patient  be  an  infant,  the  nearer 
one  can  cut  to  the  sternum  or  clavicle  the  safer  will  be  the 
operation.  Ordinarily  speaking,  this  operation  is  devoid  of 
risk,  though  at  least  one  case,  which  occurred  in  the  prac- 
tice of  Robert,  the  distinguished  French  surgeon,  was 
followed  by  death,  and  it  will  readily  be  understood  that  if 
any  of  the  cervical  veins  be  punctured  there  is  great  risk 
of  entry  of  air  into  them.  I  do  not  think  there  is  any 
great  danger  of  injuring  large  cervical  vessels,  but  *the 
external  or  anterior  jugular  veins  are  near  by,  and  may  be 
pricked,  and  if  Wounded  they  are  opened  near  their  termi- 
nation in  the  subclavian,  so  that  if  air  were  to  enter  them 
there  would  be  great  danger,  but  usually  the  result  would 
be  only  a  clot  which  would  become  absorbed.  Robert's 
case  died  of  purulent  infection  after  wounding  of  the 
external  jugular.  It  is  better  to  give  an  anaesthetic,  one 
assistant  fixing  the  shoulders,  and  depressing  that  towards 
which  the  head  is  inclined,  another  holds  the  head, 
endeavouring  to  correct  the  deformity  so  as  to  render  the 
retracted  muscle  prominent,  and  at  the  same  time  to 
increase  the  distance  between  it  and  the  carotid  and 
internal  jugular.  It  is  better  to  divide  the  sternal  and 
clavicular  parts  through  separate  punctures. 

The  question  as  to  the  safer  mode  of  dividing  the 
muscle  has  arisen,  i.e.,  whether  it  should  be  cut  from  before 
backwards,  or  vice  versa.  I  have,  always  adopted  the  latter 
mode  as  the  safer,  for  in  the  case  of  any  jerk  when  cutting 
towards  the  main  vessels,  a  serious  accident  might  arise.  The 
tenotome  is  passed  on  the  flat  behind  the  tendon  to  be  cut,  a 
little  above  the  clavicle,  its  cutting  edge  is  then  turned  to- 
wards the  skin,  and  a  careful  sawing  motion  is  imparted  until 

H 


98  BODILY    DEFORMITIES. 

the  tendon  is  felt  to  give  way.  The  knife  is  withdrawn,  a  pad 
of  oiled  lint  is  placed  upon  the  puncture,  which  is  covered 
with  strapping,  and  a  bandage  is  put  over  all.  In  dividing 
the  clavicular  portions,  some  surgeons  think  it  is  better  to 
cut  from  before  backwards,  as  then  there  is  less  risk  of 
wounding  the  external  jugular ;  but  I  have  never  adopted 
this  plan,  and  I  have  never  known  the  external  jugular  to 
be  wounded.  When  the  tendons  have  been  divided,  the 
deformity  will  be  much  more  easily  reduced,  but  the  head 
should  be  returned  to  its  deformed  position  for  three  days, 
and  then  the  wry- neck  instrument,  which  must  be  got  ready 
before  the  operation  be  undertaken,  may  be  adjusted,  and 
the  deformity  gradually  rectified.  Frictions,  massage,  and 
manipulation  must  also  be  used  while  the  instrument  is 
being  worn,  and  the  patient  encouraged  to  exercise  volun- 
tary control  over  the  muscle  which  has  been  sectionized. 
The  time  during  which  the  apparatus  must  be  worn  will  vary 
according  to  the  cause,  nature  and  degree  of  the  deformity, 
and  ranges  from  one  to  three  or  more  months  in  severe  cases. 
The  treatment  of  spasmodic  wry-neck  is  anything  but 
satisfactory.  In  the  cases  in  which  it  appears  of  a  neurotic, 
or  reflex  nature,  the  cause  of  these  must  be  ascertained 
if  possible,  and  worms,  carious  teeth  and  other  such  causes 
must  of  course  be  attended  to.  Quinine,  iron  and  other 
tonics,  with  gymnastics  of  the  affected  muscles,  may  be  of 
service  ;  but  various  anti-spasmodics,  electricity  and  other 
means  have  often  proved  unavailing,  as  also  has  tenotomy. 
I  well  recollect  the  late  Mr.  Campbell  de  Morgan's  case 
of  spasmodic  torticollis  which  at  last  became  permanent, 
and  saw  his  operation  of  excision  of  a  portion  of  about  a 
quarter  of  an  inch  of  the  spinal  accessory.  This  case  was 
ultimately,  practically  cured.  I  have  on  five  occasions 
either  stretched  or  excised  portions  of  this  nerve  either 
before  or  after  tenotomy  (at  a  subsequent  sitting),  but  can- 


TORTICOLLIS    OR    WRY-NECK. 


99 


not  speak  very  favourably  of  the  results  of  the  operation, 
and  I  think  the  experience  of  most  surgeons  and  neurolo- 
gists will  agree  with  mine,  but  as  several  cases  have  been 
benefited  by  it,  I  will  say  a  few  words  as  to  the  best  mode 
of  proceeding. 

Division,  stretching,  &c,  of  spinal  accessory. — If 
two  horizontal  lines,  the  upper  passing  outwards  from  the 
angle  of  the  jaw,  the  lower  from  the  upper  border  of 
the  thyroid  cartilage,  be  drawn,  they  will  form,  with  the 
anterior  and  posterior  border  of  the  sterno-mastoid,  a 
parallelogram.  The  spinal  accessory  forms  a  diagonal 
to  this  geometrical  figure  running  from  its  upper  angle  to 
the  lower  and  outer.     An  incision  three  to  four  inches  long 


Fig.  41. — Collar  for  wry-neck. 

should  be  made  close  to  the  posterior  border  of  the  muscle, 

commencing  a  little  above  the  upper  horizontal  line,  and 

ending  just  below  the  lower,  the  transverse  cervical  nerve 

may  be  seen  and  should  be  gently  displaced.     The  cervical 

fascia  should  be  opened,  and  when  the  posterior  border  of 

the  sterno-mastoid  is  seen,  this  should  be  lifted  up  and 

forwards,  and  usually  there  will  be  no   difficulty  in  finding 

the  nerve  piercing  it.     Guerin  has  recommended,  myotomy 

h  2 


TOO 


BODILY    DEFORMITIES. 


instead  of  tenotomy  in  cases  of  spasmodic  and  rotatory 
wry-neck,  because  in  dividing  the  muscle,  he  thinks  that  at 
the  same  time  one  may  divide  many  of  the  filaments 
supplying  it,  but  it  should  be  recollected  that  after  union  has 
taken  place,  experience  has  shown  that  the  malady  returns. 
Instruments. — The  accompanying  figures  will  suffi- 
ciently explain  the  action  of  these.  The  collars  are  most 
suitable  where  a  permanent  support  is  necessary,  as  in  cases 
of  paralysis,  but  they  have  not  sufficient  control  in  cases 
due  to  muscular  retraction.  In  these  cases,  the  head  sup- 
ports, or  Minerva's  must  be  used.  The  latter  to  be  service- 
able must  be  capable  of  four  kinds  of  movements,  that  is 
to  say,  of  flexion,  extension,  lateral  inclination,  and  rota- 
tion.    The  joint  may  be  a  ball  and  socket  one,  as  in  the 


Fig.  42.  —  Instrument  with 
ball  and  racket-joint  for  wry- 
neck. 


Fig.  43. — Instrument  with  key  and 
racket-joint  for  wry-neck. 


adjoining  figure,  and  this  instrument  I  have   found  very 


TORTICOLLIS    OR    WRY-NECK. 


IOI 


useful,  or  it  may  be  worked  with  a  key  as  the  next  illustra- 
tion shows.  The  fixed  point  is  by  means  of  a  pelvic  band, 
there  are  two  arm  crutches,  and  an  upright  along  the  spine 
to  which  the  head-piece  is  attached.  The  head  is  fixed  in 
the  proper  position  between  the  cervical  branches  as  shown  ; 
and  two  straps,  one  passing  across  the  forehead,  and  another 
beneath  the  chin,  keep  the  head  in  position.  The  instru- 
ment should  always  be  worn  at  night,  but  it  should  be  taken 


Fig.  44. — Apparatus  for  elastic  control  of  affected  muscle. 

off  for  ten  minutes  night  and  morning,  and  the  patient 
instructed  to  exercise  the  muscles  on  the  diseased  side. 
The  collar  may  be  substituted  for  night  wear  if  the  Minerva 
be  irksome. 

In  milder  cases,  an  apparatus  for  elastic  extension  is  very 
serviceable,  and  is  represented  in  the  accompanying  illus- 
tration. 


IC2  BODILY    DEFORMITIES. 


OSSEOUS    AND   ARTICULAR   TORTICOLLIS. 

In  the  chapter  on  vertebral  caries,  cervical  spondylitis  is 
discussed,  but  here  it  will  be  well  to  devote  a  little  space 
to  the  consideration,  somewhat  in  detail,  of  the  deformities 
secondary  to  bone  and  joint  lesions  of  the  cervical  spine. 

Muscular  torticollis  rarely  produces  osseous,  i.e.,  leads  to 
anchylosis,  though  osseous  and  articular  disease  always 
produce  contraction  and  retraction  of  the  muscles. 

Causes. — This  disease  may  be  due  to  (i)  injuries  of  the 
spine,  such  as  dislocations  or  fiacture-dislocations  ;  (2)  to 
uni-lateral  disease  of  the  occipito-atloid  or  atlo-axoid  joints  • 
(3)  to  disease  of  the  cervical  intervertebral  joints  ;  (4)  to 
caries  or  Pott's  disease  of  the  cervical  bodies,  and  (5)  to 
congenital  deformity  of  the  bones  or  joints.  As  regards 
the  first  set  of  causes,  the  orthopsedic  surgeon  will  have  to 
be  on  the  look-out  for  injury,  as  a  cause,  in  the  rare  cases  of 
torticollis  due  to  such  cause  which  present  themselves  at 
an  orthopaedic  institution.  The  differential  signs  must  be 
sought  in  general  text-books.  The  second  cause  of  the 
deformity  is  often  due  to  tubercular  or  rheumatic  disease, 
and  the  muscles  of  the  side  opposite  to  the  bones  diseased 
often  become  contracted.  The  joint  disease  may  end  in 
anchylosis,  but  oftener  in  destruction  of  the  joint  or  joints, 
and  suppuration  with  extension  of  the  disease  to  the  bodies 
and  intervertebral  substances  may  ensue,  and  a  chronic  tor- 
ticollis then  results,  and  is  due  to  reflex  contraction  of 
several  of  the  cervical  muscles  accommodative  to  the 
diseased  articulation.  This  torticollis,  when  the  diseased 
vertebrae  have  become  anchylosed,  is,  of  course,  permanent 
and  often  extreme.  The  same  remarks  apply  to  the  third 
cause,  and  the  fourth  is  spoken  of  in  the  section  on  verte- 
bral caries.     With  regard  to  the  congenital  deformity,  suffi- 


TORTICOLLIS    OR    WRY-NECK.  103 

cient  pathological  material  does  not  exist  for  a  satisfactory 
explanation. 

Symptoms. — It  is  here  only  necessary  to  consider  the 
symptoms  due  to  joint  mischief  in  uni-lateral  synovitis. 
The  least  rotation  of  the  head  causes  great  pain  in  the 
nape,  radiating  to  the  sides  and  front  of  the  neck,  and  up 
the  back  of  the  head,  which  is  kept  fixed  in  one  position, 
so  that  the  patient  turns  bodily  round  to  look  at  anything ; 
while  in  muscular  torticollis,  rotation  is  permitted.  Eating 
is  peculiar,  and  carefully  performed.     Swallowing  may  be 


Fig.  45. — Extreme  deformity,  the  result  of  cervical  caries.     Posterior  view. 

painful  and  difficult,  owing  to  the  formation  of  post  pharyn- 
geal abscess.  The  head  is  commonly  supported  by  the 
hands.  The  cervical  spines  are  irregular,  and  often  there 
is  swelling  and  pain  at  the  back  of  the  neck,  and  the  sub- 
occipital groove  may  be  more  or  less  absent,  but  in  thin 
people  it  is  almost  always  present,  while  in  fat. ones  it  is 
naturally  absent  and  is  therefore  useless  as  a  diagnostic 
sign.  In  a  late  stage  of  the  disease  secondary  dislocations 
gradually  occur,  and  the  resulting  deformity  is  partly  due 
to  the  direction  and  extent  of  the  articular  mischief,  and 
partly   to    reflex   muscular    contractions.      The    displaced 


104  BODILY    DEFORMITIES. 

vertebral  bodies  can  be  felt  through  the  pharynx,  and  the 
projecting  or  irregular  spines  can  be  palpated  posteriorly. 
In  congenital  deformity,  and  in  some  of  the  acquired,  the 
head  is  flexed  on  the  sternum,  or  is  thrown  backwards 
(cervical  lordosis  with  bulging  of  bodies  in  the  pharynx), 
and  the  head  seems  partly  buried  between  the  shoulders. 

Diagnosis. — In  osseous  torticollis,  the  inclination  and 
rotation  of  the  head  are  on  the  same  side,  while  in  muscu- 
lar, the  inclination  is  on  the  same,  and  rotation  on  the 
opposite  side.  In  articular  torticollis  these  may  vary,  and 
are  accommodative  to  the  muscular  contraction  and  to  the 
extent  of  the  articular  disease. 

Muscular  contraction  or  retraction  in  muscular  torticollis 
is  permanent.  In  the  osseous  variety,  the  muscles  only 
contract  under  certain  conditions,  as  in  the  gradual  change 
due  to  pathological,  or  communicated,  or  accidental  move- 
ments, and  the  contraction  usually  affects  most  of  the 
cervical  muscles  instead  of  the  sterno-mastoid  only. 

The  pain  in  spondylitis  or  arthritis  is  dull,  and  radiates 
to  the  neck  and  head ;  whereas  in  muscular  disease  it  is  in 
the  muscle,  and  the  least  movement  increases  it. 

Muscular  tension  is  extreme  in  the  muscular  form,  but 
usually  much  less  in  the  osseous,  and  when  the  torticollis 
becomes  fixed  by  anchylosis,  the  contraction  is  moderate, 
though  a  deep  resistance,  even  under  anaesthesia,  may  be 
felt. 

Prognosis. — As  regards  deformity,  this  is  almost  always 
permanent,  though  its  degree  will  vary  according  to  whether 
the  case  have  been  seen  early,  and  then  properly  treated. 
As  regards  life,  there  is  great  risk  in  disease  of  the  first  and 
second  cervical  vertebrae,  and  in  occipito-atloid  mischief, 
and  cases  of  death  from  sudden  dislocation,  or  suffocation 
from  bursting  of  a.  retro  pharyngeal  abscess  into  the  larynx, 
from  pyeemia  or  spinal  meningitis,   have   been   recorded. 


TORTICOLLIS    OR    WRY-NECK. 


IOi 


Death    may  also    result   from    extension  of   inflammatory 
mischief  to  the  spinal  or  cranial  cavities. 

Treatment.— This  will  be  given  in  the  chapter  on  spinal 
caries,  and  consists  mainly  in  absolute  rest  in  the  recum- 
bent position,  and  firmly  fixing  the  cervical  spine,  and 
counter-irritation  in  the  early  stages.  Extension,  as  shown 
in  the  annexed  illustration,  is  of  great  value  if  judiciously 
applied. 


Fig.  46. — Apparatus  for  fixing  and  extending  in  cervical  caries. 


Io6  BODILY   DEFORMITIES. 


CHAPTER  VIII. 


CYPHOSIS. 


Definition. — This  is  a  symptom  characterised  by  pos- 
terior curvature  of  part  or  whole  of  the  spinal  column. 
Most  orthopaedists  and  surgical  writers  have  classed  the 
posterior  deformity  resulting  from  carious  vertebral  bodies 
under  this  head,  but  it  is  better  to  treat  this  latter  malady 
separately  under  the  heading  of  vertebral  or  spinal  caries, 
and  to  adhere  to  the  accepted  term  of  angular  curvature 
to  denote  it.  Cyphosis  means  round  or  bent-backed,  and 
the  deformity  may  be  due  to  various  causes. 

Synonyms.  —  French,  Lor  dose ;  German,  Spitzbuckel, 
Winkelformige  Knickung  der  Wirbelsdule,  Riickverbiegung 
der  Wirbelsdule;  English,  Spinal  ex curvation  or  posterior 
defoi-mity. 

Varieties. — It  may  be  partial  or  complete,  and  a  good 
clinical  classification  is  into  infantile,  juvenile,  and  senile. 
It  may  also  be  essential  and  idiopathic  or  symptomatic. 
The  first  variety  is  rare  in  infancy  (always  understanding 
that  I  am  not  speaking  of  cyphosis  as  the  term  has 
hitherto  been  used),  and  when  found,  is  due  to  rickets  or 
Pott's  disease.  Juvenile  cyphosis,  i.e.,  when  it  occcurs 
in  children  or  adolescents,  is  more  common,  and  senile  or 
professional  cyphosis  is  commoner  still,  but  essential  < 
cyphosis  though  more  common  than  idiopathic  lordosis,  is 
far  less  common  than  scoliosis. 


CYPHOSIS.  107 

Causes  and  Seat. —  Some  writers,  as  Bouvier  and 
Bouland,  look  upon  scoliosis,  cyphosis  and  lorolojis  as 
exaggerations  of  the  normal  spinal  curves,  and  there  is,  in 
my  opinion,  not  a  little  to  favour  this  view,  seeing  that 
many  cases  of  these  deformities  occur  frequently  in  the 
regions  where  these  curves  physiologically  exist ;  but  there 
are  many  exceptions  to  the  rule  which  yet  require  thorough 
elucidation.  Partial  cyphosis  usually  occurs  in  the  dorsal 
region,  and  in  the  upper  half  or  two  thirds  of  it.  In  com- 
plete cyphosis  there  is  a  general  curve  from  the  seventh 
cervical  to  the  last  lumbar,  and  in  some  severe  cases  the 
cervical  spine  is  also  involved. 

As  is  well  known,  at  birth  there  are  no  curvatures,  and 
this  can  be  easily  demonstrated  by  placing  an  infant  on  its 
back,  which  will  be  found  in  contact,  in  almost  its  whole 
extent,  with  the  bed  or  table  on  which  it  has  been  placed, 
so  that  it  is  only  at  a  later  period,  when  the  child  has 
become  accustomed  to  sit  and  stand,  that  the  antero-pos- 
terior  curvatures  are  developed.  These  are  produced  by 
muscular  action  so  as  to  maintain  equilibrium  of  the 
spinal  axis,  which  the  weight  of  the  child's  body  tends 
constantly  to  displace.  These  antero-posterior  curves 
become  gradually  formed,  and  increase  as  the  child  is  able 
first,  to  hold  its  head  erect,  and  secondly,  to  walk.  We 
then  get  an  anterior  cervical  curve,  a  posterior  dorsal  one, 
and  the  anterior  lumbar  convexity,  and  these  three  cur- 
vatures compensate  each  other,  and  tend  to  strengthen  the 
column  and  protect  it  and  its  contents  against  shocks. 

The  Brothers  Weber  thought  that  in  the  neck  and  loins 
the  curvature  depended  chiefly  on  the  form  of  the  inter- 
vertebral discs,  and  that  in  the  dorsal  region  it  was  due  .to 
the  more  wredge-shaped  formation  of  these  vertebras. 
Hirschfeld,  on  the  contrary,  asserts  that  he  never  found 
notable  differences  between  the  height  of  the  anterior  and 


108  .  BODILY   DEFORMITIES. 

posterior  surfaces  of  the  vertebrae,  and  he  attributes  the 
production  of  these  curves  to  the  ligamenta  flava.  Coulomb 
attributes  to  the  alternative  diminution  in  front  and  behind 
of  the  intervertebral  discs,  the  chief  role  in  the  production 
of  these  physiological  curves,  and  considers  that  the  per- 
sistence of  these  curves  is  due  to  the  action  of  the  liga- 
menta flava  added  to  the  retraction,  gradually  increasing, 
of  the  anterior  and  posterior  ligaments,  and  also  to  the 
weight  of  the  upper  portion  of  the  trunk  and  limbs.  It 
would  thus  seem  most  probable  that  the  production  of 
idiopathic  cyphosis  and  lordosis,  is  due  to  the  repeated  and 
non-compensated  action  of  the  causes  just  given,  and  these, 
if  allowed  to  progress  unchecked,  lead  to  severe  and  per- 
manent changes  in  the  bones  and  articulations.  The 
deformity  may  also  be  hereditary,  or  it  may  be  due  to 
mechanical  causes  acting  on  the  spine  affected  with  rachitis 
adolescentium  •  and  the  senile  forms  may  be  induced  by 
gout  or  rheumatic  arthritis. 

Pathology.— Museum  specimens,  which  are  chiefly  taken 
from  well  marked  cases  of  long  standing,  show  that  the 
anterior  parts  of  the  discs  and  vertebral  bodies  are  com- 
pressed ;  that  the  transverse  processes  are  separated  from 
each  other,  and  that  the  laminae  are  flattened  and  shortened, 
and  in  some  cases  the  spinous  processes  are  also  further  apart 
than  natural.  The  vertebrae  most  commonly  affected  are 
the  5th,  6th,  and  7th  dorsal ;  next  in  frequency  come  the 
3rd,  4th,  9th,  and  10th,  and  last  of  all,  are  the  6th  and  7  th 
cervical.  In  some  cases  the  intervertebral  discs  only  mea- 
sure in  front  half,  or  even  less,  of  their  usual  height.  The 
essential  part  of  the  malady  consists  in  the  diminution  of 
the  height  of  the  spine  in  front,  and  the  deformity  is  nothing 
but  an  exaggeration  of  the  normal  posterior  dorsal  curve. 
In  severe  cases,  the  diminution  of  the  bodies  amount  to 
nearly  a  half  of  their  natural  height. 


CVPHOSIS.  I09 

In  cyphosis  which  has  lasted  a  long  time,  or  in  the  senile 
form  of  the  malady,  the  intervertebral  discs  may  have 
disappeared,  and  the  bodies  have  became  anchylosed  either 
center  ally  ox  peripherally.  In  the  former,  the  adjoining  sur- 
faces of  the  vertebral  bodies  become  fused,  and  bony  anchy- 
losis between  the  laminae,  articular  processes  and  the  spinous 
processes  occurs.  In  peripheral  anchylosis  it  is  the  anterior 
common  ligament  which  becomes  ossified,  so  that  these 
terms  refer,  the  latter  to  the  surrounding  ligamentous  struc- 
tures with  little  involvement  of  the  bone,  whereas  the  former 
applies  to  primary  changes  in  the  bones  and  intervertebral 
discs. 

This  disease,  which  is  commonest  in  the  dorsal  region, 
produces  noteworthy  changes  in  the  thorax,  the  vertical  and 
transverse  diameters  of  which  are  diminished,  while  its 
antero-posterior  diameter  is  usually  increased,  and  these 
changes  will,  of  course,  vary  according  to  the  form  and 
extent  of  the  curve  ;  so  that  a  slight  cyphosis  affecting  the 
dorsal  region  will  produce  little  or  no  noteworthy  deformity, 
whilst  if  the  disease  be  partial  and  severe,  the  thoracic  defor- 
mity is  more  marked.  A  transverse  section  of  such  a 
thorax  would  show  it  to  be  an  ellipsoid  larger  in  front  than 
behind.  The  intercostal  spaces  are  diminished,  the  ribs 
become  more  or  less  straightened,  the  upper  ones  being 
nearly  perpendicular  to  the  spine,  the  lower  very  oblique. 
The  sternum  is  usually  convex  in  front,  but  in  extreme 
cases  where  the  deformity  is  marked,  it  may,  however,  be 
depressed  in  its  middle  part. 

Symptoms :— In  Infantile  Cyphosis,  which  is  often 
rachitic,  the  most  frequently  observed  symptom  is  a  curva- 
ture in  the  dorso-lumbar  region,  while  in  Juvenile  Cyphosis 
the  dorsal  region  about  its  middle  part  is  more  commonly 
affected.  The  existence  of  these  projections,  and  the  fact 
that  the  subjects  usually  carry  their  heads  forwards  with 


IIO  BODILY    DEFORMITIES. 

the  chin  approaching  the  sternum,  the  shoulders  raised,  and 
carried  forwards,  the  posterior  borders  of  the  scapulae  stand- 
ing out,  so  that  the  fingers  can  be  passed  between  them 
and  their  corresponding  ribs,  are  enough  to  indicate  the 
nature  of  the  deformity.  Tamplin  has  drawn  attention  to 
the  occurrence  of  sub-scapular  crepitation  in  some  of  these 
cases,  and  this  may  probably  be  due.  in  rachitic  cases  to 
the  scapula  gliding  over  the  beads  on  the  ribs.  A  com- 
pensatory lumbar  lordosis  occurs  in  cases  of  long  standing, 
and  in  such  cases  the  patient's  belly  projects,  and  the  walk 
of  the  subject  is  peculiar,  in  that  the  trunk  is  carried  back- 
ward, so  as  to  maintain  equilibrium.  Sometimes  cyphosis 
and  scoliosis  co-exist. 

Juvenile  Cyphosis  occurs  most  frequently  about  the  age 
of  puberty,  and  is  more  common  in  girls  than  boys.  It 
may  be  due  to  a  general  laxity  of  the  system,  or  of  the 
spinal  muscles  and  ligaments,  or  it  may  be  due  to  a  rachitis 
adolescentum  aggravated  by  vicious  attitudes.  It  may  also 
be  due  to  bad  positions  in  writing  and  sewing  at  school. 

Senile  or  professional  cyphosis  occurs,  as  the  terms  con- 
vey, in  older  subjects,  and  is  induced  by  certain  positions 
repeatedly  assumed  in  one's  vocation  in  life.  Its  patho- 
logical result  is  usuallv  much  more  severe,  and  has  been 
indicated  when  speaking  of  the  anchyloses  which  occur, 
and  the  deformity  which  it  produces  is  usually  much  more 
marked  and  intractable.  Dyspnoea,  palpitations,  and 
interference  with  the  abdominal  viscera,  though  occurring 
in  minor  degrees  in  neglected  juvenile  cyphosis,  are  not 
uncommon  in  the  senile  forms  of  the  malady.  In  this 
disease  the  patient  carries  the  head  bent  forward,  and  in 
bad  cases  the  chin  touches  the  sternum,  and  the  patient's 
spine  is  very  much  curved,  so  that  he  will  generally  require 
two  sticks  to  walk  with.  As  one  wrould  expect,  this  malady 
is  more  common  in  males,  but  I  doubt  not  that  many  of 


CYPHOSIS. 


Ill 


us  have  seen  one  or  two  old  women  thus  severely  deformed 
perambulating  the  London  streets  as  match-women.  In 
less  severe  cases,  the  subject  can  maintain  equilibrium  by 
bending  the  hips  and  knees,  and  carrying  the  pelvis  back- 
wards ;   but  as  the  malady,  which,  in  some  cases,  is  due  to 


Fig.  47. —  Severe  cervico-dorsal  kyphosis. 

rheumatic  arthritis  or  gout,  progresses,  the  posterior  spinal 
muscles  are  much  weakened,  and  cannot  replace  the  bent- 
forward  spine. 

Diagnosis. — The  existence  of  the  disease  is  not  difficult 
to  establish,  but  it  is  less  easy  to  differentiate  whether  the 
malady  be  essential  or  symptomatic  of  rachitis,  caries,  gout, 


112  BODILY    DEFORMITIES. 

or  rheumatism.  The  form  of  the  curvature  will  assist  us 
in  differentiating  it  from  Pott's  disease,  because  in  the 
latter  it  is  usually  angular,  whereas  it  is  rounded  in  the 
former ;  moreover  in  Pott's  disease  one  or  more  spinous 
processes  stand  out  in  a  way  quite  different  from  that 
which  occurs  in  cyphosis,  though  in  some  cases  of  caries 
the  curvature  is  more  rounded  than  usual.  Pain  is  almost 
always  present  in  some  stage  of  spinal  caries,  whereas  it  is 
not  a  very  common  complication  in  the  ordinary  forms  of 
cyphosis,  unless  this  be  due  to  rachitis,  rheumatism  or  gout. 
Other  symptoms  will  usually  be  present  in  Pott's  disease  ; 
such  as  increased  reflex  movements,  abscess,  paraplegia,  &c. 

In  rachitic  cyphosis,  other  evidences  of  the  general 
malady  will  usually  be  present ;  such  as,  enlargement  of 
the  epiphyses,  beading  of  the  ribs,  &c.  ;  but  in  rachitis, 
which  is  localized  in  the  spinal  column,  the  differential 
diagnosis  becomes  more  difficult,  and,  as  cyphosis  is  com- 
monest in  the  dorsal  region,  if  it  be  due  to  rachitis,  the 
contraction  of  the  middle  part  of  the  thorax,  and  the 
enlargement  at  its  base,  will  aid  us  in  arriving  at  a  correct 
conclusion  as  to  its  aetiology. 

It  must  be  borne  in  mind  that  infants  when  put  in  the 
sitting  position,  always  curve  the  spine  posteriorly,  and  if 
they  be  large  and  heavy,  and  lax,  this  curve  is  more  pro- 
nounced and  must  not  be  confounded  with  cyphosis.  This 
natural  posterior  flexion  disappears  in  dorsal  decubitus,  as 
does  also  an  idiopathic  incipient  juvenile  cyphosis.  In 
infants,  this  posterior  general  curvature  is  due  to  lack  of 
power  in  the  muscles  and  ligaments  to  keep  the  spine 
erect,  and  is  a  temporary  phenomenon  which  disappears  as 
the  child  grows.  Another  diagnostic  aid  in  rachitic 
cyphosis  is  the  dyspnoea  which  usually  occurs  in  them,  and 
which  results  from  the  feebleness  of  the  spinal  muscles 
and  the  compression  of  the  lungs  by  the  deformed  thorax 


CYPHOSIS. 


"3 


against  the  diaphragm.  A  simple  method  will  aid  in  the 
diagnosis  of  the  kind,  and  degree  of  curability,  of  the 
cyphotic  curve.  Place  the  infant  on  its  belly,  and  lift  it  by 
its  feet,  then  cautiously  raise  its  pelvis,  when  rachitic  curva- 
tures will  disappear  and  a  little  physiological  lordosis  will 
reappear.  Those  curvatures  which  have  had  time  to 
become  confirmed  at  the  expense  of  the  anterior  part  of 
the  vertebras,  will  not  entirely  disappear,  but  their  ampli- 
tude and  volume  will  become  diminished.  I  have 
repeatedly  put  this  observation  to  the  test,  and  can  speak 
as  to  its  validity  in  cases  which  come  to  us  in  a  compara- 
tively early  stage,  but  if  rachitic  cyphosis  be  well  marked, 
and,  especially  if  it  be  of  the  juvenile  form,  it  is  not  so 
easy  to  make  a  marked  impression  upon  the  curve. 

I  have  said  so  much  regarding  this  disease,  because  such 
cases  naturally  come  more  frequently  under  the  care  of  the 
orthopaedic  surgeon  than  that  of  general  hospital  surgeons 
or  practitioners,  but  I  would  warn  those  of  small  experi- 
ence in  the  treatment  of  deformities,  never  to  forget  that  in 
most  cases  of  posterior  curvature  occurring  in  infants  or 
children,  the  deformity  is  due  to  caries,  and  not  to  any  of 
the  forms  of  cyphosis  as  I  have  defined  the  malady. 

Prognosis. — This  will  depend  upon  the  degree  of  the 
malady  and  its  cause.  The  infantile  and  juvenile  forms 
are  usually  quite  curable  if  the  proper  treatment  be 
adopted ;  as  are  also  the  senile  forms  in  an  early  stage,  but 
when  anchylosis  has  taken  place,  little  or  nothing  can  be 
done,  though  some  surgeons,  such  as  Delore  of  Lyons, 
have  gone  so  far  as  to  break  the  anchylosis,  and  with  a 
certain  amount  of  success.  I  have  only  once  as  yet 
adopted  this  heroic  measure,  therefore  I  would  not  pre- 
judge it  without  further  experience,  for  it  maybe  that  there 
are  suitable  cases,  and  that  such  may  derive  considerable 
benefit.     The    symptomatic    forms    of   the    malady    are 


ii4 


BODILY   DEFORMITIES. 


generally  less  amenable   to  treatment   than   the   essential 
varieties. 

Treatment. — In  the  first  and  second  stages  this  malady- 
is  quite  curable,  but  when  anchylosis  has  taken  place,  the 
spine  can  only  be  very  partially  straightened,  and  then  by 
very  forcible  and  therefore  dangerous  extension.  I  have 
only  once  tried  this  plan,  and  the  amelioration  produced 
was  encouraging.     I  think  that  there  could  not  have  been 


Figs.  48  and  49. — Diagram  of  dorsal  kyphosis  before  and  after  application  of  a  spring 

corrector. 


bony  anchylosis,  or  but  a  slight  one,  though  considerable 
force  was  required  to  correct  the  mal-position,  and  a  crack- 
ling noise  was  distinctly  audible.  No  ill  effects  followed, 
and  I  think  that  in  this  affection,  and  in  the  second  stage 
of  scoliosis,  this  operation  in  cases  deemed  suitable,  is 
quite  justifiable  so  far  as  present  experience  goes.  It  is  a 
very  different  matter  to  attempt  straightening,  as  do  some 
of  the  bone  setters  and  quacks,  in  cases  of  Pott's  disease, 
where  paraplegia  or  other  serious  lesion  to  the  cord  may 
result :  but  in  the  disease  just  named,  the  only  theoretical 
mischief  which  might  accrue  would  be  an  inflammation 


CYPHOSIS. 


115 


due  to  the  rupture  of  strong  fibres  or  ligamento-osseous 
bands,  and  it  is  possible  that  this  might  extend  to  the 
intervertebral  substances,  producing  inflammation  of  them, 
and  also  ostitis  and  caries,  but  these  are  only  a  priori  con- 
siderations. If  operation  be  deemed  not  desirable,  the 
treatment  of  this  malady  is  local  and  general.  The  latter 
applies  itself  to  the  improvement  of  the  health  by  suitable 
regimen  and  medication,  whereas  the  former  makes  use  of 
gymnastics  and  appliances  which  tend  gradually  to  correct 
the  deformity.  There  is  one  exercise  recommended  by 
Shaw  and  Andry  which  I  have  not  found  to  succeed.  It 
is  to  make  the  patient  carry  weights  upon  the  head  so  as 
to  exercise  the  enfeebled  muscles,  and  encourage  them  to 
bring  the  spine  into  a  better  direction.  It  seems  to  me 
that  the  usual  result  is  failure,  as  the  spinal  muscles  are 
already  so  weak  that  the  patients,  unless  forced,  shun  the 
proceedings.  Auto-suspension  by  Sayre;s  apparatus  may 
be  tried,  but  I  place  more  faith  in  improving  the  general 
health,  massage,  electricity,  and    supports.     In   the  third 


Fig.  50. — Nyrop's  spring  corrector. 

stage,  where  bony  anchylosis  has  occurred,  our  treatment 
can,  as  a  rule,  only  be  palliative. 
Spinal  Correctors  and  Supports. — The  best  of  these 

1  2 


u6 


BODILY    DEFORMITIES. 


appear  to  me  to  be  the  spring  support  of  Nyrop,  and  the 
apparatus  of  Lebelleguie.  The  former  is  shown  in  the 
accompanying  figure,  but  it  should  be  borne  in  mind  that 
the  supports  are  only  adjuncts  to  the  other  treatment,  and 
should  be  worn  between-whiles  ;  and  I  would  also  draw 
attention  to  the  fact  that  they  need  modification  according 
to  special  circumstances.  Many  other  forms  of  apparatus 
have  been  devised ;  such  as,  Taylor's  support  for  Pott's 


Fig.  51.— Nyrop's  spinal  corrector  applied. 


disease,  and  Duchenne's  bandage,  acting  by  elastic  trac- 
tion ;  but  those  I  have  recommended,  and  the  accompany- 
ing figure  of  one  made  by  Mr.  Schramm,  added  to  those 
already  indicated,  will  serve  every  purpose  in  cases  amen- 
able to  treatment.  In  infants,  a  leather  posterior  support 
properly  padded  will,  with  attention  to  its  fitting,  render 
aid  in  correcting  this  deformity. 

Spinal  Debility. — In    delicate     and    rapidly-growing 


CYPHOSIS. 


117 


children,  and  especially  in  girls,  this  condition  is  indicated 
most  usually  by  a  general  or  partial  cyphosis.  In  some 
cases  there  may  be  combined  flexion,  or  even  slight  atonic 
scoliosis.  This  abnormal  condition  of  the  spine  is  due  to 
want  of  constitutional  and  local  muscular  tone,  and  is 
aggravated  by  bad  positional  habits.    The  spine  can  usually 


Fig.  52. — Apparatus  for  spinal  debility. 

be  readily  corrected  by  the  surgeon  or  patient,  but  easily 
relapses  into  its  former  condition.  The  best  treat7?ient  is 
by  attention  to  the  general  health,  fresh  air,  gentle  exercise, 
and  the  exhibition  of  tonics.  Locally  massage,  and  elec- 
tricity in  some  cases,  are  very  valuable,  and  an  instrument 
like  Nyrop's,  which  acts  as  a  spinal  reminder,  is  very  ser- 
viceable. 


Il8  BODILY   DEFORMITIES. 


CHAPTER    IX. 

LORDOSIS. 

Definition. — This  malady  consists  in  a  marked  hollow 
in  the  back,  due  to  anterior  curvature  of  the  portion  of  the 
spinal  column  in  which  it  occurs.  It  is  less  common  than 
cyphosis,  which  latter  is,  as  has  already  been  pointed  out, 
far  less  common  than  scoliosis. 

Synonyms. — French,  Lor  dose  ;  German,  VorverMegung 
der  Wirbelsaule,  Lordotische  skoliose  ;  English,  Spinal  incur- 
vation or  anterior  deformity. 

Varieties. — It  may  be  essential,  i.e.,  idiopathic,  or  symp- 
tomatic, and  is  commonest  in  the  lumbar  region,  though  it 
may  occur  in  the  dorsal  and  cervical.  Idiopathic  lordosis 
is  rare,  and  when  it  occurs  is  usually  developed  at  an  early 
age.  Lumbar  lordosis  is  common  in  some  races,  as  among 
Cuban  women,  and  the  inhabitants  of  Terra  del  Fuego,  and 
even  in  some  Europeans  there  is  an  exaggeration  of  the 
normal  physiological  antero-posterior  curve  which  must 
not  be  mistaken  for  lordosis  proper.  This  also  consists 
in  a  great  aggravation  of  the  normal  curve  in  a  subject  pre- 
viously not  so  deformed.  Certain  domestic  animals,  espe- 
cially horses  which  have  carried  heavy  weights  upon  their 
back,  have  well  marked  lordosis,  and  this  condition  can 
be  readily  produced  by  interbreeding.  Syptomatic  lordosis 
may  be  due  to  several  causes,  such  as  primary  deformity 
of  the  lumbar  vertebrae,  congenital  dislocation  of  the  hip, 


LORDOSIS. 


II9 


hip  disease  and  anchylosis,  or  it  may  be  compensatory  to 
dorsal  angular  curvature,  and  is  also  found  in  very  stout 
people  with  pendulous  abdomen  and  fat  omentum. 

Causes. — Some  of  these  have  been  given,  so  far  as 
known,  under  the  above  heading.  Certain  occupations, 
such  as  carrying  weights  on  the  head,  cause  a  balancing 
of  the  spine  by  throwing  the  upper  part  of  the  trunk  back- 


Fig.  53. — Upper  dorsal  lordosis  in  a  boy  aged  10. 

wards,  and  produce  what  may  be  termed  a  vocational 
lordosis.  Pregnancy  will  produce  a  temporary  lordosis, 
whereas  rapidly  repeated  pregnancies,  partly  by  this 
mechanical  effect,  and  partly  by  debilitating  the  constitution 
and  abdominal  muscles,  may  render  it  pen?ianent.  Large 
abdominal  tumours,  whether  ovarian,  uterine,  or  other  will 
produce  temporary  lordosis,  and  contraction  of  the  posterior 


120 


BODILY    DEFORMITIES. 


spinal  muscles  will  also  produce  it,  and,  paradoxical  as  it 
may  appear,  paralysis  of  these  muscles  will  also  cause  it. 

Paralysis  of  the  spinal  muscles  causes  the  patient  to 
throw  the  trunk  backwards  so  as  to  prevent  its  falling  in 
the  opposite  direction,  which  tendency  is  induced  by  the 
action  of  the  unaffected  flexors.  In  these  cases  the  buttocks 
are  much  diminished  or  nearly  effaced,  the  pelvis  is  tilted 
forwards  and  upwards,  so  that  a  leaded  cord  passing  from 
the    occipital   protuberance    will   hang    well    behind   the 


Figs.    54  and   55.— Lordosis  from    paralysis  of    abdominal    muscles  (Bouvier).— 
Lordosis  from  paralysis  of  the  pelvic  extendors  (Duchenne). 


sacrum.  If  the  abdominal  muscles  which  act  as  flexors  of 
the  spine  be  paralyzed,  lordosis  will  also  result,  but  this  is 
limited  to  the  lumbar  or  lumbosacral  region,  and  the 
leaded  cord  will  come  in  contact  with  the  sacrum  because 
the  pelvis  is  rotated  so  that  its  anterior  spines  look  down 
and  forwards,  and  the   tubera  ischii   back   and   upwards. 


LORDOSIS.  I2T 

Paralysis  of  the  cervical  muscles  will  produce  cervical 
lordosis,  and  it  matters  little  whether  the  disease  affect  the 
flexors  or  extensors.  The  mechanism  of  this  is  similar  to 
that  just  explained  with  reference  to  lordosis  due  to 
paralysis  of  the  adominal  or  spinal  muscles.  Congenital 
lordosis  is  extremely  rare.  Other  rare  forms  are  the 
temporary  lordosis  of  infants  due  to  reflex  irritation  from 
teething,  worms,  &c,  and  that  resulting  from  central  or 
peripheral  nervous  lesion  or  irritation.  Instances  of  these 
are  given  in  the  next  paragraph. 

Symptoms.— These  will  vary  according  to  the  seat  of 
the  deformity.  Cervical  lordosis  is  very  rare,  is  commonest 
in  infants  at  the  breast,  and  this  is  due  to  the  debility  of 
the  anterior  cervical  muscles,  which  are  not  yet  sufficiently 
developed  to  hold  the  head  erect ;  but  this  is  a  mere 
transitory  symptom,  and  cannot  be  considered  a  pathological 
cervical  lordosis  ;  but  I  have  seen  three  well-marked 
instances,  two  of  which  occurred  in  infants,  and  one  in  a 
girl  aged  seven.  In  all  of  these  the  posterior  cervical 
muscles  felt  harder  than  natural,  and  the  occiput  was 
approximated  to  the  nape,  and  the  chin  projected.  The 
infants  were  cured  in  from  two  to  three  months  by  correct- 
ing their  diet,  attending  to  the  wrong  condition  of  the 
alimentary  canal,  by  frictions  and  massage  to  the  muscles 
of  the  nape,  and  by  a  proper  support.  But  in  the  girl, 
nearly  six  months  elapsed  before  the  deformity  was  cured, 
and  here  I  had  to  call  in  the  aid  of  electricity,  local 
gymnastics,  and  a  support  to  be  worn  day  and  night. 

In  lumbar  or  lumbo-sacral  lordosis  there  is  a  great  hollow 
in  the  lumbar  region,  the  upper  part  of  the  body  is  thrown 
backwards,  the  buttocks  project,  and  the  walk  of  the 
patient  is  peculiar,  and  must  be  seen  to  be  understood 
and  remembered.  The  abdomen  is  prominent,  the  scapulae 
are  thrown  back  and  upwards,  and  the  shoulders  back,  in 


122 


BODILY   DEFORMITIES. 


the  early  stages,  but  when  a  compensatory  dorsal  cyphosis 
is  formed,  these  latter  symptoms  are  absent.  If  the  patient 
be  made  to  lie  on  the  back,  a  marked  arch  will  be  observed 
between  the  buttocks  and  dorsal  region.  It  will  be  under- 
stood that  this  deformity,  if  primary,  causes  a  tilting 
forwards,  and  rotation  of  the  pelvis  on  its  transverse  axis, 
so  that  in  women  an  alteration  of  the  pelvic  viscera  must 
occur;  hence,  these  subjects  are  liable  to  uterine  displace- 
ments and  to  troubles  during  childbirth,  and  it  is  well  to 
instruct  these  women  to  lie  on  their  back  for  some  months 
before  their  expected  confinement,  with  their  thighs  flexed 
upon  the  pelvis  and  supported  by  pillows.  Symptomatic 
lordosis  scarcely  ever  assumes  so  pro- 
nounced a  curve  as  does  the  essential, 
or  idiopathic  form. 

Pathology. — The  vertebrae  and  inter- 
vertebral discs  of  the  part  affected  are 
higher  in  front,  the  spinous  processes 
are  diminished  in  height,  as  also  are 
the  articular  processes  and  the  laminae, 
the  posterior  aspects  of  which  become 
convex.  The  transverse  processes  are 
also  approximated.  In  extreme  cases, 
anchylosis  of  these  vertebral  processes 
may  occur,  but  less  commonly  than 
in  cyphosis.  Anchylosis  may  even 
occur  between  the  bodies,  and  this  may 
be  peripheral,  occurring  only  at  their 
margins,  or  central.  In  lumbar  or 
lumbo-sacral  lordosis,  the  sacral  verte- 
Fig.  56.— Paralytic  lor-  brai  angle  is  increased,  and  the  coccyx 

dosis  in  a  male  child  from  .  • 

atrophy  of  spinal  muscles,   points  upwards  and  backwards,  so  that 
the  pelvis  is  rotated  in  the  same  direc- 
tion.    The  pelvic  brim  becomes  cordiform  in  shape  and  its 


LORDOSIS.  123 

anteroposterior  diameter  is  diminished,  though  in  idio- 
pathic lordosis,  usually,  no  serious  obstacle  is  offered  to 
childbirth.  The  anus  and  the  external  genitals  are  carried 
backwards,  and  the  uterus  predisposed  to  ante-version. 

Diagnosis. — The  deformity  declares  itself.  The  only 
question  is  to  ascertain  its  cause,  and  if  it  be  symptomatic ; 
this  is  usually  not  difficult.  Many  forms  of  the  latter  dis- 
appear on  dorsal  decubitus,  or  on  standing,  such  as  the 
paralytic,  and  those  due  to  anchylosis  of  the  hip,  but  if 
an  attempt  be  made  to  straighten  the  thigh,  lordosis  is 
reproduced.  In  women,  if  uterine  troubles  exist,  these 
will  of  course  aggravate  the  symptoms,  but  usually  the 
prognosis  as  regards  the  general  health  is  favourable,  and 
in  cases  of  symptomatic  lordosis,  the  deformity  will 
diminish  or  disappear,  if  its  cause  be  amenable  to  surgical 
treatment. 

Treatment.— This  consists  in  properly  selected  and 
guarded  gymnastics,  electrization  of  the  abdominal  muscles, 
recumbency,  and  the  use  of  apparatus.  The  patient's  bed 
or  couch,  if  used  in  the  daytime,  should  be  so  disposed 
that  the  head  and  shoulders,  also  the  pelvis  and  lower 
limbs,  should  be  raised  above  the  intermediate  region, 
which  will  thus  tend  to  straighten  itself.  In  lumbar  lordosis 
a  support  with  a  pad  pressing  upon  the  secondary  dorsal 
cyphosis,  should  be  used  in  the  intervals  between  the  other 
modes  of  treatment.  In  paralytic  cases,  besides  electricity, 
massage,  and  suitable  medication,  elastic  or  steel  spring 
supports  are  of  considerable  service. 


124  BODILY   DEFORMITIES. 


CHAPTER   X. 

VERTEBRAL    OR    SPINAL    CARIES,    OR    SPONDYLITIS. 

Definition.— This  is  a  disease  of  the  vertebral  bodies  or 
intervertebral  segments  which  leads  to  their  partial  or  com- 
plete destruction,  and  is  completed  by  anchylosis  causing 
posterior  projection  of  the  spinous  processes.  It  is  properly 
called  spondylitis  (from  anovftvXos,  a  vertebra)  and  has  also 
been  called  Pott's  Disease,  though  other  surgeons,  and 
especially  Camper  and  Severin,  described  it  before  him, 
yet  not  so  accurately. 

Synonyms. — English,  Angular  curvature ;  Greek,  Ky- 
phosis;    German,  Spitzbuckel,  Winkelformige  Knickung  der 
Wirbelsdule  ;  French,  Cyphose,  Mai  de  Pott. 

Varieties.— There  are  the  lumbar,  dorsal,  and  cervical 
forms  of  the  disease,  and  when  the  malady  affects  contiguous 
regions,  it  is  termed  cervico-dorsal  or  dorso-lumbar  accord- 
ingly. The  pathological  changes  are' the  same  in  all  these 
varieties.  It  may  also  be  acute  or  chronic,  the  former  run- 
ning its  course  sometimes  very  rapidly. 

Causes.— It  was  formerly  believed  that  tubercle  in  the 
bodies  of  the  vertebras  caused  inflammation,  softening,  and 
decay,  which  spread  to  the  intervertebral  substances,  and 
ate  away  the  bodies,  producing  a  cavity  on  the  anterior 
^  or  antero-lateral  aspects  of  the  affected  portion  of  the  spine 
S  which  led  to  ultimate  collapse,  and  the  formation  of  a 
posterior   projection;  but  the    late  Mr.   Hilton,  and  Mr. 


SPINAL    CARIES.  I  25 

Holmes  in  this  country,  and  Dr.  Sayre  of  America  hold 
that  the  mischief  is  very  commonly  set  up  by  injuries,  in 
fact  the  latter  surgeon  goes  so  far  as  to  say  it  is  always  due 
to  traumatism.  He  says,*  "  The  most  frequent  causes  of 
Pott's  disease  are  concussions  and  blows.  A  child  un- 
usually active  and  playful  may,  in  some  careless  prank, 
jump  from  a  height  in  such  a  manner  as  to  come  down 
straight,  with  the  lower  limbs  quite  rigid  at  the  knees  and 
hips,  and  thereby  give  a  sudden  concussion  to  the  bodies 
of  the  vertebrae,  and  the  intervening  cartilaginous  discs,  thus 
disturbing  some  centre  of  ossification  to  such  an  extent  as 
to  result  in  inflammatory  action,  and  finally  in  soften- 
ing and  disintegration  of  bone.  In  consequence  of  a  blow 
or  fall,  the  heads  of  some  of  the  ribs  may  be  forcibly 
driven  against  their  articular  facets.  In  many  instances 
direct  blows  are  received  of  sufficient  force  to  injure  the 
vertebrae,,  and  to  excite  disturbance  of  a  serious  character. 
Pott's  disease  occasionally  originates  in  fracture  of  a  trans- 
verse process  of  a  vertebra,  the  injury  remaining  un- 
suspected, until  at  last  it  may  be  discovered  quite  by 
accident,  in  the  post-mortem  theatre,  or  the  dissecting  room. 
In  many  cases  of  angular  curvature,  the  fact  that  any  injury 
had  been  received  prior  to  the  development  of  the  disease, 
has  passed  entirely  unrecognized  by  either  the  patient  or 
his  friends,  and  has  been  revealed  only  after  the  most  care- 
ful questioning.  After  such  disturbance  of  one  or  more 
vertebrae,  several  months  may  elapse  before  attention  is 
drawn  to  the  case,  and  probably  during  this  interval,  the 
bones  may  have  been  partially  destroyed  through  inflam- 
matory softening  and  disintegration,  and  more  or  less 
distortion  may  have  been  developed.  Any  signs  of  exhaus- 
tion that  may  now  be  presented  are  regarded  as  evidence 
of  constitutional  cachexia,  but  erroneously  so,  since  the 
*  "  Spinal  Disease  and  Spinal  Curvature,"  London,  1877,  p.  2. 


126  BODILY    DEFORMITIES. 

exhausted  condition  of  the  patient  is  simply  the  result  of 
long-continued  suffering  from  a  local  disease,  dependent 
upon  some  direct  injury  to  the  parts  in  fault." 

I  have  given  Dr.  Sayre's  views  in  his  ipsissima  verba, 
because,  though  I  freely  admit  that  injury  may  frequently 
be  the  actually  known  or  the  unrecognized  cause  of  the 
disease,  I  cannot  admit  it  as  the  only  cause,  and  to  the 
exclusion  of  others  due  to  local  and  constitutional  states. 
If  we  reflect  on  the  many  thousands  of  children  in  exist- 
ence, and  of  the  tumbles  and  hurts  of  various  kinds  which 
the  majority  must  have  in  their  childhood  and  youth,  and 
compare  them  with  the  number  of  cases  of  Pott's  disease 
met  with  in  practice,  whether  public  or  private,  we  should 
see  that  one  is  out  of  all  proportion  to  the  other.  Thus, 
even  assuming  that  injury  be  the  exciting  cause  in  all  cases, 
it  appears  necessary  to  call  in  a  constitutional  or  local  pre- 
disposition, to  explain  the  occurrence  of  spondylitis  in  the 
instances  in  which  it  occurs  after  a  hurt.  We  must  all 
know  of  cases  of  severe  spinal  injury  followed  by  perfect 
recovery,  and  of  other  cases  in  which  a  slight  injury 
appears  to  have  evoked  spinal  caries,  so  that  the  amount  of 
traumatism  does  not  appear  to  be  a  very  important  factor, 
and  here  again  we  are  obliged  to  call  in  the  aid  of  some 
predisposing  cause.  In  the  cases  in  which  the  force  of  the 
blow  is  transmitted  through  the  ribs  to  the  vertebral 
articular  facets,  it  is  more  probable  that  an  arthritis  is  set 
up  which  may  spread  through  the  processes  to  the  vertebral 
bodies,  and  thus  cause  the  disease.  Of  this  I  am  sure, 
that  in  considering  cases  of  spinal  caries,  we  too  often  over- 
look the  undoubted  fact  that  disease  of  the  vertebral  joints 
may  co-exist,  or  even  be  independently  present.  The  fact 
that  the  disease  is  commoner  in  boys  than  in  girls,  lends 
support  to  the  traumatic  view,  as  they  are  more  exposed  to 
injury  in  their  rougher  games.     It  is  but  right,  however,  to 


SPINAL    CARIES.  I  27 

mention  that  Dr.  Sayre  admits  the  presence  of  constitu- 
tional tendencies  in  some  cases  where  injury  was  the  excit- 
ing cause. 

Tubercle  and  syphilis  are  not  infrequent  causes  of  the 
disease  ;  and  ostitis  with  cheesy  degeneration  may  follow 
the  continued  fevers,  or  be  due  to  vital  depression  from 
some  long  or  serious  illness.  This  deformity  may  also  be 
caused  by  cancer  or  tumours  originating  in,  or  extending 
to,  the  bodies  of  the  vertebrae,  or  be  due  to  the  erosion 
caused  by  aneurisms.  The  deformity  may  also  be  imitated 
by  gout  and  rheumatism,  or  occasioned  by  an  ostitis  and 
arthritis  deformans.  Fracture  and  dislocation  also  lead  to 
posterior  spinal  projections. 

Symptoms.— In  its  early  stage  these  are  often  obscure, 
and  consist  chiefly  in  various  local  or  distant  pains,  and 
reflex  disturbances.  This  is  due  to  irritation  or  pressure 
on  the  spinal  nerves  at  the  intervertebral  foramina,  and  the 
situation  of  the  mischief  can  be  diagnosed  in  the  prae- 
cyphotic  stage  by  the  pain  in  the  side  or  front  of  the  body 
which  is  not  infrequently  complained  of.  In  the  early 
stages  of  dorsal  caries,  pain  along  the  intercostal  nerves 
and  abdomen,  intrathoracic  pains,  palpitations,  irregular 
breathing,  and  indigestion  may  be  present,  and  cases  not  a 
few,  might  be  quoted  in  which  the  patient  has  been  treated 
for  these  symptoms  rather  than  for  the  disease  producing 
them.  In  lumbar  disease,  in  its  early  stage,  a  feeling  of 
constriction  around  the  abdomen  may  be  present,  and  a 
pain  on  deep  pressure  at  the  sides  of  the  umbilicus ;  there 
is  pain  on  walking,  and  on  abducting  the  thighs,  and  not 
uncommonly,  pain  down  the  inner  side  of  the  thigh.  There 
may  also  be  constipation,  flatulence  and  reflex  irritations, 
so  that  such  symptoms  may  be  mistaken  as  due  to  worms. 
The  bladder  or  rectum  also  may  be  very  irritable.  Any 
of  these  symptoms  should  lead  to  an  examination  of  that 


128  BODILY    DEFORMITIES. 

part  of  the  spine  where  the  nerves  of  these  organs  take  their 
exit.  In  cervical  caries  in  its  early  stages,  there  are  fre- 
quently present,  dysphagia,  rigidity  of  the  cervical  muscles, 
and  sometimes  a  feeling  of  strangulation.  Laryngeal  irri- 
tation may  also  be  present,  and  pains  at  the  upper  part  of 
the  thorax.  Another  symptom  in  cervical  or  cervico-dorsal 
caries,  in  the  early  stages,  is  a  slight  torticollis  or  opistho- 
tonis,  and  the  sufferer  dislikes  holding  the  head  erect  or 
rotating  it.  There  is  a  painful  expression  of  face,  and  the 
patient  walks  with  a  peculiar  gait  indicative  of  great 
caution.  Very  soon  a  compensating  posterior  dorso-lumbar 
curve  appears,  which  may  mislead  one  into  thinking  this  to 
be  the  primary  affection.  The  shoulders  appear  raised, 
and  the  head  sunk  between  them,  and  the  latter  is  often 
supported  by  the  hand  of  the  patient.  If  the  first  or 
second  cervical  vertebra  be  affected,  occipital  neuralgia  will 
frequently  be  present,  as  the  great  and  sub-occipital  nerves 
cross  along  this  region. 

Should  irregular  diaphragmatic  action  be  present,  the 
vertebrse  through  which  the  fourth  and  fifth  cervical  nerves 
emerge  will  be  the  parts  diseased.  Mr.  Howard  Marsh  * 
correctly  says  that,  as  a  rule,  in  cervical  caries  the  pain 
is  situated  at  a  higher  level,  whereas  in  disease  of  the  lower 
portions  of  the  spine  it  is  generally  found  at,  or  below,  the 
seat  of  mischief.  In  later  stages,  retro-pharyngeal  abscess 
may  be  present,  and  will  assist  in  the  diagnosis,  and  in  the 
last  stage,  deformity  will  leave  no  doubt  as  to  the  nature  of 
the  malady.  And  this  last  statement  holds  true  of  disease 
in  the  other  spinal  regions.  It  should  be  pointed  out,  how- 
ever, that  pharyngeal  abscess  often  causes  laryngeal  spasm 
and  pressure,  and  if  not  opened  early  may  lead  to  the 
necessity  for  tracheotomy. 

Besides  the  vague  pains  which  may  be  present  in  these 
*  British  Medical  Journal,  June  nth,  18S1. 


SPINAL    CARIES.  I  29 

cases,  there  are  various  reflex  muscular  contractions  in  the 
early  stages,  and  these  are  noticeable  in  the  various  actions 
of  the  patient,  in  the  way  he  walks  or  holds  himself,  or 
turns  round.  The  joints  of  the  lower  limbs  are  bent  so  as 
to  avoid  any  sudden  concussion.  The  spinal,  and  often 
the  abdominal  muscles,  are  kept  rigid  and  the  shoulders 
elevated,  in  order  to  prevent  movement  between  the  verte- 
bral bodies,  and  the  patient's  locomotion  is  extremely 
guarded.  The  spine  is  kept  rigid  so  as  to  prevent  move- 
ment and  pressure  on  the  vertebrae,  which  cause  pain,  and 
the  patient  when  asked  to  stoop  or  take  up  anything  from 
the  floor  does  so  in  a  peculiar  way  by  first  bending  the  hips, 
then  the  knees,  until  he  reaches  the  object,  when  he  raises 
himself  by  placing  his  hands  on  his  knees  or  on  some  near 
object,  such  as  a  chair,  and  rises  slowly,  keeping  the  spine 
stiff  the  whole  time.  The  respiration  is  also  short  and 
noisy,  and  the  object  of  this  rapid  respiration  is  to  throw 
less  work  on  the  muscles  acting  through  the  ribs  on  the 
affected  vertebrae. 

Another  diagnostic  aid  is  to  ask  the  patient  to  rise  from 
a  chair,  and  in  the  case  of  a  child  it  will  be  found  that 
it  will  gradually  and  painfully  slide  down  so  as  to  avoid 
any  spinal  concussion,  and  an  adult  will  rise  by  resting  his 
hands  on  the  sides  or  back  of  a  chair,  or  on  his  knees. 
By  questioning  the  mother,  or  observing  the  child  at  play, 
or  getting  in  or  out  of  bed,  it  will  be  observed  that  a  slight 
jar  produces  an  expression  of  pain,  and  the  one  with 
which  I  have  been  familiar  at  the  East  London  Child- 
ren's Hospital,  and  at  the  London  Hospital  is  the  cry  of 
Oh-er.  The  behaviour  of  the  patient  during  sleep  will  also 
furnish  valuable  information,  as  the  child  is  often  restless 
and  moans  or  utters  short  cries  when  attempting  to  move, 
whereas  in  hip  or  knee  disease,  motion  in  bed  is  usually 
provocative  of  a  sharp  scream,   without  waking.     If  the 

K 


130 


BODILY    DEFORMITIES. 


child  be  placed  upon  a  bed  or  on  the  floor  and  asked  to 
get  up  it  will  generally  roll  over  to  get  up  on  the  hands  and 
knees,  and  then  on  the  feet.  The  observation  of  children 
as  they  stand  may  furnish  valuable  observation,  as  they  not 
infrequently  rest  one  or  both  hands  upon  the  thigh  so  as  to 
support  the  spine  through  collateral  transmission  of  weight. 

These  remarks  hold  true  simply  of 
children.  In  adults  there  is  of 
course  less  difficulty  in  eliciting  in- 
formation. 

In  the  later  stages,  if  the  disease 
progress,  we  have  abscess  pointing 
in  various  directions,  following  or 
accompanying  posterior  deformity, 
and  these  will  guide  us  as  to  the 
exact  site  of  the  mischief.  If  the 
disease  progress  partially,  or  com- 
pletely, paralysis  of  one  or  both 
lower  limbs  may  occur,  or  of  the 
upper  ones  in  cervical  or  cervico- 
dorsal  mischief;  but  paraplegia  is 
commonest  when  the  disease  is  low 
down,  and  may  depend  either  upon 
effusion  around,  or  into,  the  cord, 
or  on  myelitis,  or  on  vertebral  dis- 
placement. Generally,  this  paralysis 
recovers  sooner  or  later  as  the 
diseased  process  subsides,  and  I  have 
recently  seen  a  case,  in  an  adult,  of  five  years  of  paraplegia 
due  to  spinal  caries  which  ultimately  recovered  and  almost 
without  treatment,  except  frictions  of  the  affected  limbs. 
In  cases  which  are  going  to  the  bad,  oedema  of  the  lower 
limbs  and  lower  part  of  the  abdomen  and  of  the  genital 
organs  may  occur  ;  or  death  may  be  ushered  in  by  hectic 


Fig.  57.  —  Lower  dorsal 
(Pott's)  and  slight  right  mor- 
bus coxae.  Showing  how 
these  cases  stand  and  fix 
spine  by  the  hands  on  knees. 


SPINAL   CARIES. 


131 


and  exhaustion  from  the  abscess,  or  through  lardaceous 
disease  caused  by  profuse  suppuration.  Tuberculosis  also 
has  resulted  from  prolonged  suppuration.  Bladder  symp- 
toms, and  even  the  formation  of  calculus  has  been  caused 
from  a  long  continued  recumbent  position  and  the  difficulty 
thereby  caused  in  thoroughly  evacuating  the  bladder. 

In  the  dorsal  region  pain  would  be  referred  to  parts  on  a 
level  with,  or  below,  the  diseased  region.  The  intercostal 
muscles  act  imperfectly  and  respiration  is  largely  abdominal, 
but  in  the  lower  dorsal  region  abdominal  pains  are  com- 
plained of  and  the  child  prefers  the  prone  position.  In 
the  early  stages  the  spine  is  rather  incurved,  but  in  later 
stages,  when  the  bodies  are  crumbling  away,  the  spinous 
processes  begin  to  project  and  then  the  case  is  clear;  but 
in  its  incipiency  the  peculiarity  in  walking  and  speaking 
and  the  rigidity  of  the  column  will  guide  us  to  the  diagnosis 
of  vertebral  ostitis.  In  dorso-lumbar  disease  there  is  a  ful- 
ness and  sometimes  fluctuation  in  the  ilio-costal  spaces 
before  any  bony  deformity  can  be  recognized. 

In  lumbar  caries  we  have  a  guide  through  the  condition 
of  the  psoas  muscles,  as  there  is  often  a  preference  for 
standing  upon  one  leg,  or  a  lameness  of  one  or  other  limb 
with  flexion  of  the  thigh ;  but  the  motions  of  the  hip  are 
perfect  and  painless,  at  any  rate  in  the  earlier  stages. 
These  symptoms  as  wrell  as  abscess  may  appear  before 
deformity. 

As  the  disease  progresses  the  deformity  of  the  spine 
assumes  various  shapes,  being  sometimes  curved,  but  more 
often  angular.  In  the  former,  several  vertebrae  share  in 
the  projection,  in  the  latter,  the  spinous  processes  of  one 
vertebra  is  more  prominent  then  those  of  the  remainder. 
In  the  dorsal  region,  the  natural  curve  of  which  is  back- 
wards, the  projection  appears  sooner  and  the  spinous  pro- 
cesses project  more  than  they  do  in  other  regions  ;  whereas 

k  2 


132 


BODILY   DEFORMITIES. 


in  the  lumbar  region,  which  is  concave  posteriorly,  the 
posterior  deformity  is  much  longer  in  showing  itself,  as  the 
anterior  lumbar  curvature  has  to  disappear  before  a  pos- 
terior projection  can  be  formed ;  but  in  the  lower  lumbar 
and  upper  sacral  vertebrae  a  lordosis  of  the  vertebrae  above 
the  disease  is  not  an  uncommon  symptom  preceding 
posterior  projection.     As  the  disease  progresses  the  spinal 


Fig.  58. — Lumbosacral  caries  and  severe  angular  deformity. 


muscles  become  atrophied  and  allow  the  angle  or  curve,  to 
become  more  prominent. 

If  the  disease  progress  to  the  formation  of  abscess  this 
may  be  recognized  by  certain  general  and  local  symptoms. 
The  temperature  rises  and  may  even  reach  105,  as  recorded 
by  Shaffer.  Pain  along  the  course  of  the  abscess  is  usually 
present,  though  there  are  not  a  few  cases  in  which  all  the 
symptoms  are  obscure.     There  may  be  neuralgic  pains  in 


SPINAL   CARIES.  1 33 

the  neck,  along  the  intercostal  spaces,  or  in  the  loins, 
groins,  and  thighs,  according  to  the  region  of  the  disease  ; 
and  in  lumbar  disease  the  peculiarity  of  standing  and 
walking  and  the  position  of  the  lower  limb,  already  alluded 
to,  will  be  present,  and  it  will  be  found  that  the  patient 
can  go  better  up.  than  down  stairs.  Psoas  abscesses  may 
open  down  the  thigh  and  leg,  or  may  ascend  on  the  abdo- 
minal muscles,  or  may  even  pass  along  the  inguinal  canal 
and  be  mistaken  for  an  inguinal  rupture,  and  they  may  pass 
over  the  iliac  crest  and  open  on  the  gluteal  muscles.  They 
may  also  pass  out  through  the  sacro-sciatic  foramina,  or 
may  burst  into  the  bladder  or  rectum.  In  the  next  para- 
graph on  pathology  I  mention  a  case  of  cervical  disease 
and  post-pharyngeal  abscess,  the  latter  passed  into  the 
posterior  mediastinum  and  caused  fatal  pleurisy ;  and  I 
also  had  a  case  of  syphilitic  caries  at  the  London  Hospital 
a  few  years  back  in  which  the  boy  coughed  up  portions  of 
vertebrae  which  had  penetrated  the  lung.  The  abscesses 
are  sometimes  of  considerable  size,  and  I  have  known  a 
double  psoas  so  distend  the  abdomen  and  pelvis  of  a  girl 
as  to  be  mistaken  for  ascites,  ovarian,  or  other  tumour  ;  and 
a  case  has  recently  been  recorded  in  the  Laiicet  in  which 
abscesses  following  spinal  caries  enormously  distended  the 
abdomen.  Xot  long  since  I  had  a  case,  aged  50,  at  the 
Hospital  for  Women,  of  a  hard  tumour  in  the  right  iliac 
fossa,  which  caused  great  pain  in  the  hip  and  thigh.  The 
patient  could  not  walk,  and  was  obliged  to  be  gently  turned 
in  bed,  and  even  this  caused  great  pain.  There  was  no 
spinal  deformity  and  but  very  slight  complaint  of  backache. 
The  pelvic  swelling  had  been  variously  diagnosed,  and  at 
one  time,  seeing  that  there  was  some  oedema  of  the  leg,  I 
was  inclined  to  regard  it  as  malignant.  In  a  few  weeks 
fluctuation  became  evident,  and  pus  accumulated  below 
Poupart's  ligament  and  I  evacuated  it.     The  diagnosis  was 


134  BODILY    DEFORMITIES. 

then  clear.  I  saw  this  woman  seven  months  afterwards, 
and  a  swelling  had  formed  on  the  opposite  side,  so  that  she 
was  the  subject  of  double  psoitis.  Deformity  was  scarcely 
perceptible. 

Sometimes  psoas  abscess  opens  into  the  hip-joint  by 
means  of  the  sub-psoas  bursa, which  occasionally  communi- 
cates with  it,  and  inflammation  and  abscess  of  this  bursa, 
by  the  pain  occasioned  along  the  psoas  and  sometimes 
referred  to  the  back,  may  cause  diagnostic  difficulty,  and 
especially  if  the  abscess  point,  as  it  may  do,  in  the  usual 
position  of  psoas  abscess.  There  are  some  cases  of  lumbar 
caries  and  double  hip-disease  which  may  be  independent,  or 
may  own  the  cause  of  bursal  complication  just  indicated. 
It  must  also  be  remembered  that  there  are  rare  cases  of 
dry  osteitis,  periostitis,  and  arthritis  in  the  spinal  as  in 
other  regions. 

Secondary  deformities,  and  combinations  of  caries  with 
lateral  curvature  are  not  infrequent.  There  may  be  com- 
pensatory lordosis  above  or  below  a  posterior  angular 
deformity,  and  the  arch  of  the  curve  or  projection  may  take 
a  lateral  direction.  In  such  case  it  would  show  that  the 
disease  had  affected  the  antero-lateral  parts  of  the  vertebrae 
on  the  side  towards  which  the  deformity  projects.  When 
the  disease  occurs  before  the  bones  have  set,  secondary 
pelvic  deformities  may  arise  and  may  be  mistaken  as  due 
to  rickets. 

Cervical  caries  has  for  its  earliest  symptoms  stiffness  of 
the  neck  and  pain  on  movement.  There  is  pain  on  gently 
pressing  the  palm  on  the  vertex  and  in  the  nape.  As  the 
disease  advances,  coughing,  sneezing,  swallowing,  and  any 
kind  of  motion  produces  pain.  In  disease  of  the  lower 
half  of  the  cervical,  spine  paralysis  of  one  or  both  arms  or 
of  the  trunk  and  limbs  may  supervene  if  pus  or  displace- 
ment compress  the  cord.     Severe  hiccough  may  result  and 


SPINAL    CARIES.  135 

be  due  to  irritation  of  the  phrenic,  or  severe  palpitation 
may  exist.  The  patient  cannot  rotate  the  head,  but  turns 
the  trunk  round  on  the  femora,  or  moves  round  on  the  feet. 
The  symptoms  of  disease  high  up  in  this  region  have  been 
given  when  dealing  with  osseous  and  articular  torticollis ; 
but  it  must  always  be  remembered  that  thorough  fixation  of 
the  diseased  part  is  absolutely  necessary  to  prevent  disloca- 
tion and  sudden  death  from  compression  of  the  medulla. 

Pathology. — The  pathological  process  may  in  its  com- 
mencement be  either  peripheral  or  central.     In  the  former, 
it  generally  commences  as  a  periostitis,  leading  to  a  super- 
ficial suppurating  ostitis  ;  in  the  latter,  the  disease  com- 
mences in  the  centre  of  the  bone,  and  is  entirely  indepen- 
dent of    the   periosteum.      In    the   peripheral   forms   the 
periosteum  becomes  first  thickened  and  then  loosened  from 
its   attachment,    and    beneath    this,   new    bone    becomes 
deposited.     Spinal  caries  may  be  dry  or  suppurative,  the 
former  being  rare  and  commonly  due  to  gout  or  rheuma- 
tism.    Shaffer  is   of  opinion  that  caries  sicca  affects  many 
vertebrae  and  leads  to  a  posterior  curvature,  whereas  in 
suppurative  caries  the  disease  affects  but  a  few  vertebra?. 
The  deformity  is,  as  a  rule,  angular.    Scrofula  and  syphilis, 
with  or  without  injury,  are  supposed  to  be  the  causes  at 
work  in  the  production  of  the  disease.     In  the  destructive 
process  the  salts  of  lime  are  absorbed  by  the  newly  formed 
vessels  and  the  cancellous  tissue  and  medulla,  in  which  are 
migratory  cells  and  osteoclasts,  gradually  erode  the  bones, 
which,  though  swollen  in  the  early  stages,   become  very 
light  and  ultimately  their  compact  or  cortical  substance  is 
eaten  away.     In  the  dry  forms  interstitial  granulations  wear 
away  the  cancellous  tissue  and  cause  extensive  deformity, 
of   course  without  suppuration.      Billroth  is  of   opinion, 
from  the  study  of  excised  joints,  that  this  form  is  almost 
never  seen  post-mortem,  as  the  granulations  would  break 


i36 


BODILY    DEFORMITIES. 


down  into  pus  during  the  very  low  state  of  the  patient 
which  precedes  death.  Cases  are  recorded  in  which  the 
mischief  began  in  the  anterior  common  ligament ;  and  I 
have  seen  one  post-mortem  in  which  it  was  confined  to  the 
intervertebral  substances,  but  these  appear  to  be  exceptional. 
As  the  disease  progresses  it  spreads  up  and  down,  and  may 
affect  the  dorso-costal  as  well  as  the  spinal  articular  pro- 
cesses. The  post-mortem  appearances  of  the  spinal  cord 
and  its  membranes  vary;  it  may  be  only  slightly  compressed 


# 


i 


*$!%&* — &• 


Fig.  59. — Diagrams  of  how  a  carious  spine  is  straightened  by  instruments  properly- 
adapted.  The  two  left  figures  are  according  to  Taylor ;  the  right  according  to  Vogt, 
and  is  more  correct. 


or  not  at  all  altered  in  shape.  The  membranes  alone,  or 
the  cord  also,  may  be  in  various  stages  of  inflammation,  or 
of  induration,  or  of  suppuration  and  softening.  If  the 
displaced  bone  press  upon  the  cord,  symptoms  of  irritation 
and  constriction  of  the  parts  affected  are  present  during 
life ;  but  as  a  rule  these  disappear,  as  the  projected  part  of 
bone  becomes  absorbed  and  rounded  off  in  time,  and  the 
angle  that  is  formed  in  the  cord  to  accommodate  itself  to  the 
altered  shape  of  the  spinal  canal  does  not  usually  affect  its 
functions,  because  the  slowness  of  the  process  permits  the 


SPINAL    CARIES.  J37 

medulla  to  become  accustomed  to  its  altered  position.     As 
the  bone  breaks  down  suppuration  increases,  and  abscesses 
form  and  pass  in  certain  directions  which  will  vary  with  the 
seat  of  the  disease.    In  the  cervical  region  they  may  be  retro- 
pharyngeal, or  may  open  at  the  front  or  back  of  the  sterno- 
mastoid,  or  more  rarely,  towards  the  back  of  the  neck  ;  and 
I  have  known  an    abscess   to    follow   the   course    of   the 
cesophagus,  and  cause  pleurisy,  pyothorax,  and  death.    If  the 
disease  be  in  the  dorsal  region,  pus  may  point  in  the  inter- 
costal regions,  or  may  gravitate  to  the  loins,  and  m  lumbar  _ 
caries  matter  usually  points  along  the  course   of  the  psoas 
muscles,  of  one   or  both  sides,  according  to  the  site  and 
extent  of  the  mischief.    It  may  not  extend  beyond  Pouparts 
ligament,  and  is  then  termed  iliac  abscess;  but  if  it  pass 
into  the  thigh  it  is  usually  called  psoas  or  femoral  abscess. 
Pus  due  to  lumbar  or  dorso-lumbar  caries  may  pass  between 
the  planes  of  fasciae  attached  to  the  corresponding  vertebrae 
and    appear   in   the   loin,    and.  is  then  known  as  lumbar 

abscess 

Diagnosis.-Most  of  the  chief  diagnostic  points  of  the 
disease,  as  affecting  the  various  regions,  have  been  pointed 
out  when  speaking  of  the  symptoms,  therefore  here  it  will 
only  be  necessary  to  speak  chiefly  of  differential  diagnosis. 
In  the  first  place,  we  must  remember  that  this  disease  is 
commonest  in  children  and  young  people,  and  if  we  recol- 
lect that  at  puberty,  and  in  girls  for  a  short  time  after,  the 
natural  adult  spinal  curves  are  not  completely  formed,  we 
shall  be  alive  to  the  fact  that  in  a  highly-flexible   column 
various  appearances  of  deformity  may  arise,  and  especially 
in  the  more  movable    parts,  such  as  the  lumbar  region. 
These  should  not  be  mistaken  for  caries.     Such  deviations 
may  be  diagnosed  by  placing  the  patient  on  the  belly  and 
raising  the  pelvis,  when   they  will  disappear,  and  no  pam 
will  be  complained  of;    whereas,  if  canes  were   present, 


138  BODILY   DEFORMITIES. 

there  would  be  pain  and  rigidity  of  the  spine.  The  atti- 
tude of  the  patient,  his  movements  when  turning  in  the 
sitting  or  lying  posture,  will  show  what  part  of  the  spine 
is  rigid.  The  old  plans  of  jolting  the  patient,  of  pressure 
and  percussion,  of  application  of  heat  along  the  spine,  are 
fallacious  and  mischievous,  as,  though  disease  be  present, 
they  may  cause  no  pain,  and  the  means  adopted  elicit 
pain  without  disease  existing.  If,  in  females,  much  pain 
be  complained  of,  or  if  slight  touches  produce  pain,  we 
should  always  suspect  hysteria,  and  by  applying  the  other 
tests  there  will  be  little  difficulty  in  arriving  at  a  satisfactory 
diagnosis.  Hysterical  paraplegia  should  not  now-a-days 
give  rise  to  much  diagnostic  difficulty. 

The  symptoms  of  spinal  caries  may  be  simulated  by 
various  maladies,  such  as  nephritis  from  various  causes, 
peri- nephritis,  peri-typhlitis,  cancer,  sacro-iliac  diseases, 
pelvic  cellulitis,  aneurisms  in  the  thorax  and  abdomen,  hip 
disease,  and  cervical,  thoracic,  abdominal  or  pelvic  neuralgia. 
Dr.  V.  P.  Gibney,  in  an  excellent  paper,*  publishes  a  case 
in  which  the  malady  was  first  thought  to  be  a  sprain, 
and  five  months  later  to  be  a  sub-acute  dorso-lumbar 
meningitis  or  coxal  neurosis ;  two  years  after  it  was  pro- 
nounced an  idiopathic  iliac  abscess,  a  month  later  it  was 
thought  to  be  lumbar  caries  with  psoas  abscesses,  and  at 
the  time  of  his  writing  the  paper  the  diagnosis  was  doubt- 
ful. Another  case  was  at  first  supposed  to  be  hip  disease, 
a  month  afterwards  to  be  lumbar  disease  with  psoas  abscess, 
and  at  the  end  of  the  year  there  were  no  signs  of  any 
disease.  I  mention  such  cases  to  show,  not  only  that  the 
symptoms  may  be  obscure,  but  that  they  will  vary  accord- 
ing to  the  stage  of  the  maladies  causing  them.  Whenever 
there  is  multiple  bone  or  joint  disease  the  spine  should 
always  be  examined,  as  cases,  not  a  few,  have  been  ob- 
*  "  The  Diagnosis  of  Pott's  Disease  of  the  Spine,"  &c.  1882. 


SPINAL    CARIES.  139 

served  and  recorded  in  which  it  became  affected  secon- 
darily or  concurrently  with  these.  Cancer,  sarcoma,  and 
chondroma  may  originate  in  the  vertebra,  or  extend  to  it, 
giving  rise  to  diagnostic  difficulty,  as  many  of  the  symptoms 
are  common  to  them  and  caries  ;  but  the  age  of  the  patient 
is  usually  a  valuable  guide,  as,  with  the  exception  of  sar- 
coma, and  sometimes  of  chondroma,  these  affections  are 
commonest  in  later  life,  though  it  must  be  remembered 
that  caries  may  occur  in  advanced  years.  Pain  and 
cachexia  are  probably  the  two  most  helpful  signs,  when 
combined,  of  malignant  vertebral  disease. 

Prognosis.— Before  Pott's  time  this  disease  used  to  be 
very  fatal,  and  chiefly  on  account  of  the  violent  methods 
of  extension  which  were  adopted ;  but  now-a-days,  judging 
from  hospital  records,  death  from  spinal  caries  is  quite 
exceptional.  This  is  partly  due  to  the  early  recognition  of 
the  disease  and  the  adoption  of  proper  treatment,  and  in 
no  small  measure  to  the  abandonment  of  all  violent  means, 
as  formerly  employed.  In  the  early  stages  correct  treat- 
ment will  cure  the  disease  without  any.  or  but  little,  de- 
formity, and  even  when  abscess  is  formed  recovery  is  the 
rule,  if  these  abscesses  do  not  involve  any  important 
viscera,  but  burst  spontaneously  and  continue  to  discharge. 
Death  may  sometimes  result  from  septicaemia,  hectic  fever, 
lardaceous  disease  of  the  viscera,  or  tuberculosis.  Death 
may  also  be  caused  by  involvement  of  the  spinal  cord  and 
its  membranes,  or  by  direct  pressure  of  displaced  bones 
upon  the  cord,  and  has  even  been  due  to  spinal  haemor- 
rhage. Such  cases  are,  however,  comparatively  rare.  The 
duration  of  the  cure  will  vary  according  to  the  stage  at 
which  the  patient  applies  for  treatment  and  the  condition 
of  his  health  at  that  period. 

Treatment.— This  is  constitutional  and  local,  the  former 
consisting  in  good  air,  food,  rest,  tonics,  and  cleanliness, 


140 


BODILY    DEFORMITIES. 


with  the  occasional  exhibition  of  alteratives  if  necessary. 
The  local  treatment  consists  in  the  judicious  use  of  various 
surgical  means,  such  as  rest  to  the  spine,  either  by  means 
of  recumbency  in  the  supine  or  in  the  prone  position,  or 
by  spinal  supports  during  the  greater  part  of  the  day.  The 
question  of  the  amount  of  recumbency  must  be  settled 
according  to  the  stage  of  the  disease  and  the  local  and 
general  condition  of  the  patient.  I  can  also  recommend 
Rauchfuss's  spinal  cradle,  as  shown  in  the  accompanying 
figure,  as  it  combines  rest  and  extension,  and  the  patient 
may  rest  in  it  in  the  supine  or  prone  position,  the  head 


Fig.  60. — Suspensory  cradle  for  rest  and  extension  during  recumbency. 


and  shoulders  being  supported  by  pillows  and  the  limbs 
acting  as  counter-extendors. 

The  plan  which  many  years'  experience  has  convinced 
me  to  be  the  best  is  to  have  a  moulded  back-splint  made  of 
leather,  felt,  or  gutta-percha,  and  covered  with  wash-leather, 
accurately  fitted  to  the  patient's  back.  This  should  fasten 
above  over  the  shoulders  and  below  round  the  pelvis, 
leaving  the  thorax  and  abdomen  free  from  compression. 
The  patient  should  lie  on  his  back  on  a  firm  mattress  in 
this  spinal  support  and  from  time  to  time  the  supine  should 
be  changed  for  the  prone  position.  I  am,  of  course,  now 
speaking  of  dorsal  and  lumbar  caries.  In  more  severe 
cases  a  water  or  air  bed  may  be  placed  beneath  the  mat- 


SPINAL    CARIES. 


141 


tress.  In  private  cases  the  mattress  should  be  so  arranged 
as  to  be  easily  removable  into  an  invalid-carriage  or  peram- 
bulator. It  should  be  always  borne  in  mind  that  the 
object  of  recumbency  is  to  give  complete  rest  to  the 
diseased  spine,  and,  therefore,  all  movements  should  be 
restricted  as  much  as  possible  ;  and  in  lumbar  disease,  in 
children,  it   is  often  a  good  plan   to  pass  a  bandage  over 


Fig.  61. —  Support  for  dorso-lum- 
bar  caries. 


Fig.   62. — Support    for    fixation    and 
counter-extension  in  dorsal  caries. 


the  thighs,  so  as  to  prevent  their  being  moved  and  causing 
traction  and  irritation  on  the  psoas  muscles. 

Spinal  Instruments —When  the  disease  has  suffi- 
ciently advanced  towards  anchylosis  a  properly  fitted 
instrument  should  be  worn,  and  slight  locomotion  alternat- 
ing with  recumbency  may  be  daily  allowed  and  gradually 
increased  as  the  symptoms  indicate.     The  indications  to 


142  BODILY    DEFORMITIES. 

be  fulfilled  by  these  machines  are  (i)  to  support  the  dis- 
eased portion  of  the  spine,  (2)  to  remove  superincumbent 
weight,  and  (3)  to  prevent  increase  of  deformity.  They 
have  been  made  of  various  forms  and  materials,  and  their 
name  is  legion.  I  need  not  occupy  valuable  time  and 
space  by  entering  into  these,  but  will  content  myself  with 
recommending  the  forms  which  experience  has  taught  me 
to  prefer,  remarking  that  I  am  not  at  all  prejudiced  in  the 
matter  of  instruments,  provided  the  indications  already 
given  be  fulfilled  by  them. 

I  do  not  intend  to  enter  into  any  lengthy  discussion  of 
Dr.   Sayre's  method  of  treatment  by  suspension  and  the 
plaister  of  Paris  jacket,  as  I  spoke  at  some  length  on  this 
subject  at  the  meeting  of  the  International  Congress  in 
London,  though  I  did  not  respond  to  the  Secretary's  desire 
to  put  my  remarks    into  writing,  so  that  they  have   not 
appeared  in  the  Volume  of  the  Transactions ;  but  I  may 
briefly  say  that  our  experience  at  the  Royal  Orthopaedic 
Hospital  has  conclusively  shown    this   plan  to  be  worse 
than  useless  in  lateral  curvature,  as  it  loses  valuable  time, 
and  that  in  caries  the  increase  of  height  gained  by  exten- 
sion disappears  in  a  few  hours  after  wearing  the  jacket. 
I  do    not  think    that    suspension   should   be   used  when 
the   disease    is    active   or    when   there   is   much   destruc- 
tion of  bone,  as  it  is  then  undoubtedly  dangerous.     That 
the  jacket  does  not  prevent  the  formation  of  abscesses, 
and   that  it    may    cause  sores    and    sloughs — even  when 
applied  by  Dr.   Sayre  himself — we  have  had  proof.     In 
hospital  practice,  where  time  and  expense  are  objects,  and 
in  cases  in   which  anchylosis  is  proceeding  favourably,  I 
think  the  jacket  a  cheap  and  efficient  support,  if  properly 
applied;  but  I  would  do  away  with  extension  altogether 
in  spinal  caries,  because  it  is  mischievous  in  the  active, 
acute,  and  destructive  stages,  and  when  anchylosis  is  pro- 


SPINAL    CARIES. 


T43 


ceeding  it  is  not  necessary,  and  may  be  harmful.  I  believe 
there  is  no  need  for  me  to  say  any  more  on  the  subject 
now-a-days,  as,  I  believe,  the  general  consensus  of  opinion 
of  British  practitioners,  and  certainly  of  orthopaedic  surgeons 
— those  most  qualified  from  large  experience  to  express  a 
competent  opinion  on  such  a  subject — is  against  Sayre's 
plan,  and  his  method  of  treatment  has  fallen  a  good  deal 
into  desuetude  in  these  countries.     Felt  jackets  are  useful, 


Fig.  63. — Taylor's  support  for  lumbar  caries. 


but  they  are  as  expensive,  and  more  so,  than  a  properly 
constructed  mechanical  support,  and,  to  my  mind,  less 
efficacious. 

When  the  cervical,  and  especially  the  upper-cervical, 
vertebrae  are  affected,  absolute  rest,  with  the  head  or  neck 
supported  between  pillows  or  sand-bags,  is  necessary  for  a 
long  period,  and  when  repair  of  the  bones  has  sufficiently 
advanced,  a   collar,   or  Minerva,   or,  in  poor  patients,   a 


144  BODILY    DEFORMITIES. 

plaister-jacket  and  jury-mast  are  very  serviceable.  Some 
of  these  machines  are  represented  in  the  section  on  osseous 
torticollis. 

The  surgical  treatment,  beyond  the  local  measures 
already  enumerated,  consists  in  the  treatment  of  abscesses, 
or  in  the  direct  treatment,  where  practical,  of  the  diseased 
bones.  In  the  early  stages  it  is  possible  to  procure  absorp- 
tion, and  I  have  seen  abscesses  slowly  disappear ;  but,  un- 
fortunately, this  is  not  the  rule,  and  then  they  need 
repeated  aspiration,  or  may  be  opened  by  a  valvular 
incision,  or  by  a  trocar  and  cannula.  Precaution  must  be 
taken  to  prevent  the  entrance  of  foul  air,  and  those  who 
prefer  it  may  adopt,  in  hospital  practice,  Listerian  precau- 
tions. I  had  for  several  years  before  the  appearance  of 
Mr.  Callender's  paper,  opened  psoas,  lumbar,  and  other 
abscesses,  and  hyper-distended  them  with  injections  of 
carbolic  solution,  Condy's  fluid,  and  other  disinfectants. 
Mr.  Julius  Csesar,  who  was  House  Surgeon  at  the  East 
London  Children's  Hospital  at  the  period  adverted  to, 
can  verify  this  statement,  but  as  I  did  not  draw  public 
attention  to  the  method,  the  merit  of  priority  must  be 
accorded  to  the  late  Mr.  Callender.  It  is  well  not  to  inter- 
fere unnecessarily  with  these  abscesses,  as  they  often  remain 
dormant  for  months  without  necessitating  any  special  treat- 
ment, but  among  the  poor,  where  the  patients  are  allowed 
to  go  about  as  long  as  they  can,  not  only  do  they  some- 
times open  quickly,  but,  curious  to  relate,  many  of  these 
cases  end  in  anchylosis,  with  or  without  great  deformity,  in 
a  perfectly  marvellous  manner. 

Posterior  incision  of  spinal  abscesses. — J.  &  E.  Bceckel  in 
Germany,  and  Israel  and  Reclus  in  France,  cut  down  on 
psoas  abscess  through  the  loin,  a  few  years  ago,  and  removed 
carious  or  necrotic  bone,  and  Mr.  Treves  has  introduced 
the  plan  into  this  country,  and  given  anatomical  guides 
for  its  performance.     His  paper  will  be  found,  in  abstract, 


SPINAL    CARIES.  145 

in  the  Proceedings  of  the  Medico-Chirurgical  Society  of 
London  for  this  year.  Mr.  Chavasse  has  lately  drawn 
attention  to  a  similar  plan  adopted  by  Mr.  Chiene,  of 
Edinburgh,  and  his  paper  appeared  in  the  Lancet  before 
Air.  Treves  read  his  paper  at  the  above-named  society. 
I  have  operated  on  one  case  with  temporary  benefit.  No 
loose  bone  was  found,  but  the  cavity  of  the  abscess  was 
scraped  as  far  as  possible,  and  washed  out.  The  operation 
was  done  some  months  ago,  and  the  boy  is  still  in  the 
East  London  Children's  Hospital,  suffering  from  diarrhoea, 
and  is  in  a  very  emaciated  condition.  The  disease  was 
dorso-lumbar,  and  there  were  sinuses  in  the  loin. 

If  thought  necessary  or  desirable,  spinal  abscess  in  the 
dorsal  region  may  be  reached  by  an  incision  along  the  rib 
passing  down  and  out  from  near  its  angle  ;  a  portion  of  the 
rib  of  sufficient  extent  may  be  removed,  and  the  abscess 
cavity  reached,  and  the  bone  dealt  with  as  may  be  required. 
The  cavity  can  then  be  scraped  and  drained. 

Cervical  abscess  and  necrosed  or  carious  bone  can  be 
reached,  if  high  up,  through  the  mouth,  and  if  lower  down, 
by  an  incision  as  for  external  cesophagotomy. 

This  method  of  surgically  dealing  with  spinal  abscesses 
is  yet  quite  young  and  on  its  trial,  but  it  seems  to  be  a 
good  and  rational  proceeding  in  cases  where  such  a  method 
is  clearly  indicated,  though,  from  what  I  have  heard  and 
seen,  the  cases,  so  far,  have  only  been  temporally  benefitted, 
and  several  have  succumbed.  I  have  also  known  the 
operation  to  be  left  incompleted  by  a  surgeon  who  had 
some  experience  in  it. 


146  BODILY    DEFORMITIES. 


PART    III. 
DEFORMITIES  OF  THE  LOWER  LIMB. 


CHAPTER  XI. 


TALIPES    OR    CLUB-FOOT. 


Definitions. —  Club-Foot  or  Talipes  signifies  an  abnormal 
position  of  the  foot,  or  its  parts,  in  its  anatomical  relations 
to  itself  or  the  leg,  and  this  abnormality  may  consist  in  a 
flexion,  extension,  abduction  or  adduction.  In  the  majority 
of  cases  the  muscles  and  their  tendons,  and  the  ligaments 
and  fascia  will  be  found  contracted  and  retracted. 

Synonyms. — German,  Klumpfuss ;  Latin,  Pes  contortus; 
French,  Pied  bot. 

Varieties. — There  are  six  typical  forms,  viz.,  1.  Pes 
Varus,  in  which  the  inner-side  of  the  foot  is  raised,  the 
anterior  portion  of  it  adducted  and  the  sole  turned  inwards. 
2.  Its  opposite,  Pes  Valgus,  in  which  the  outer-side  of  the 
foot  is  raised  and  the  sole  everted.  3.  Pes  Equinus,  in 
which  the  heel  is  raised,  and  the  subject  walks  on  the 
balls  of  the  toes.  4.  Its  opposite,  Pes  Calcaneus,  in  which 
the  toes  are  raised  and  progression  occurs  at  the  heel. 
5.  Pes  Planus,  in  which  the  sole  rests  on  the  ground,  the 
arch  of  the  foot  having  sunken.  6.  Pes  Cavus,  the  oppo- 
site of  planus,  in  which  there  is  a  great  hollow  in  the  sole, 


TALIPES    OR    CLUE-FOOT.  147 

the  arch  being  much  increased.  These  are  the  simple 
forms,  but  combinations  of  them  form  the  compound  forms, 
such  as  equino-varus  and  valgus  and  calcaneo-valgus. 
Not  infrequently  at  large  special  institutions,  mixed  forms 
are  seen,  such  as  valgus  of  one  foot  and  var"us  of  the  other, 
or  calcaneus  and  varus,  &c.  Any  of  these  forms  may  be 
either  congenital  or  acquired.  Among  the  congenital,  the 
compound  form  equino-varus,  is  the  commonest,  and 
valgus  and  planus  are  the  commonest  of  the  forms  affect- 
ing adolescents  and  adults.  Cavus  is  almost  always  an 
acquired  deformity.  Of  these,  equinus  and  calcaneus  are 
produced  through  the  tibio-astragaloid  or  ankle-joint, 
whereas  varus  and  valgus  are  brought  about  by  changes 
wrought  in  the  tarsal  bones  and  joints. 

Relative  frequency. — This  is  a  matter  upon  which 
some  writers  differ.  Most  of  them,  especially  compilers, 
have  followed  some  recognized  authority,  and  said  that 
varus  is  the  commonest  deformity ;  but  this  is  a  decided 
error,  as  the  most  frequent  form  of  congenital  club-foot 
(and  these  are  the  commonest  of  cases)  is  the  combined 
form  equino-varus.  The  statistics  of  Lonsdale,  Tamplin, 
Chaussieur,  Lannelongue,  and  Duval  give  the  following 
results  : — Of  495  cases  of  club-foot,  Lonsdale  observed  396 
which  he  calls  primitive  forms,  i.e.,  typical  forms ;  73  of  the 
compound  forms  ;  and  26  of  the  mixed  forms  ;  but  it  must 
be  borne  in  mind  that  Lonsdale's  varus,  as  that  of  all 
authors  succeeding  him,  is  equivalent  to  equino-varus. 
Of  the  primitive  forms  varus  was  the  commonest,  then 
valgus  and  equinus  about  equal — setting  aside  the  causes 
— and  calcaneus  was  uncommon.  When  speaking  of  the 
compound  forms,  he  says  he  has  only  observed  five  cases 
of  equino-varus  of  both  feet  against  fifty  four  of  varus  of 
both  feet — a  statement  which  very  much  puzzles  me. 
Males  were  much  more  frequently  affected  than  females. 

L    2 


J  48  BODILY    DEFORMITIES. 

Tamplin,  out  of  10,217  cases  of  deformity  treated  at 
the  Royal  Orthopaedic  Hospital,  only  met  with  1,780  club- 
feet, of  which  754  were  congenital. 

Chaussieur  noted  132  infants,  out  of  23,923  newly-born, 
affected  with  various  deformities,  and  thirty-seven  of  these 
had  club-feet,  but  the  nature  of  the  abnormality  is  not 
made  clear. 

Lannelongue  says  that,  of  15,229  births  at  the  Paris 
Maternity  Hospital  from  1858-67,  there  were  108  deformed 
infants,  of  which  eight  had  club-feet. 

Duval's  statistics  show  that  of  1,000  club  feet,  574  were 
congenital;  364  occurring  in  males,  and  210  in  females. 
He  also  gives  the  following  account  of  club  feet : — 


Boys. 

Girls. 

Equinus  and  equino-varus 

417     .. 

215      .. 

202 

Varus 

532     •• 

302      .. 

230 

Valgus           ...          .... 

22     .. 

14      .. 

8 

Calcaneus 

9     •• 

6     .. 

3 

Extreme  calcaneus  ... 

20     .. 

13     •• 

7 

It  will  be  observed  that  these  statistics  agree  with  those 
of  Lonsdale  with  regard  to  the  much  greater  predominance 
of  club-foot  in  males.  From  my  experience  of  ten  years 
at  the  Royal  Orthopaedic  Hospital,  I  am  sure  that  equino- 
varus  is  the  commonest  congenital  form — that  is  to  say, 
that  the  heel  is  drawn  up  by  a  shortened  tendo-Achillis, 
and  that  the  tibialis  anticus,  posticus,  and  flexor  longus 
digitorum  are  contracted,  producing  the  characteristic 
deformity.  Congenital  valgus  and  equinus  are  either 
simple,  or  combined,  and  far  less  common ;  but  congenital 
equino-valgus  is  commoner,  in  my  experience,  than  either 
of  them.  Calcaneus  is  comparatively  rare.  Dubreuil  says 
that  congenital  varus  is  much  rarer  than  equino-varus,  a 
statement  diametrically  opposed  to  all  my  experience,  so 


TALIPES    OR    CLUB-FOOT.  1 49 

that  I  may  say  that  the  so-called  typical,  primitive,  or  pure 
forms  of  the  malady  are  rare,  in  my  practice,  as  congenital 
deformities. 

Classification. — V.  Duval  proposed  a  classification 
and  nomenclature  with  long  Greek  words,  which  I  need 
not  occupy  space  with  here,  as  it  is  more  a  question  of 
terminology.  Bonnet  proposed  a  classification  founded 
on  normal  anatomy  and  physiology,  but  which  will  not 
stand  pathological  test.  Observing  that,  usually,  varus  is 
associated  with  equinus,  and  valgus  with  calcaneus,  and 
that,  in  the  first  place,  the  affected  muscles  are  supplied  by 
the  internal  popliteal,  whilst,  in  the  second,  the  contracted 
muscles  are  supplied  by  the  external  popliteal,  he  estab- 
lished two  kinds  of  club-foot,  viz.,  internal  and  external 
popliteal  club-foot,  and  in  this  he  has  been  followed  by 
Mr.  Richard  Davy ;  but  Malgaigne,  a  long  time  since, 
shattered  this  theory  by  pointing  to  the  fact  that  typical 
calcaneus  exists,  and  that  this  is  a  contradiction  to  Bonnet's 
theory,  and  also  that  the  tibialis  anticus,  though  supplied 
by  the  external  popliteal,  powerfully  contributes  to  inward 
deviations  of  the  foot. 

Causes.— It  has  already  been  said  that  club  foot  may  be 
congenital  or  acquired,  and  the  causes  will  vary  concur- 
rently. There  can  be  little  doubt  of  the  power  of  heredity 
in  some  instances,  and  I  have  known  several  striking  illus- 
trations in  which  some  form  of  club  foot,  and  generally  the 
commonest  form,  equino-varus,  ran  through  various  mem- 
bers of  the  same  family.  Consanguineous  marriages  are 
also  said  to  be  productive  of  deformities  generally,  and  this 
kind  among  them.  The  various  theories  as  to  the  causes 
of  congenital  club  foot  may  be  arranged  under  three  heads  : 
1.  Mechanical ;  2.  Muscular;  and  3.  Osseous  malforma- 
tion, or  arrest  of  development. 

Hippocrates,  Pare,  and  Cruveilhier  were  supporters  of 


150  BODILY    DEFORMITIES. 

the  first  view,  and  thought  that  abnormal  pressure  of  the 
uterus  on  the  foetus  through  deficient  liquor  amnii,  or  com- 
pression of  the  uterus  by  another  part  of  the  foetus,  or  the 
abnormal  position  and  action  of  the  umbilical  cord  or  of 
the  amniotic  bands,  would  produce  club  foot.  But  against 
this  view  the  objections  were  that  in  most  cases  of  club 
foot  it  is  impossible  to  find  any  compressing  cause,  either 
external  or  internal.  Mr.  Silcock  and  Messrs.  Parker  and 
Shattock  have  recently  advocated  the  view  of  mal-position 
in  utero  as  producing  the  deformity,  and  the  dissections 
and  microscopic  examinations  of  the  latter  gentlemen  show, 
that  from  two  cases  examined,  they  regard  congenital  club 
foot  as  due  to  mal-position  in  utero ;  but  this  only  indicates 
to  me  that  in  these  two  cases  muscular  or  nervous  change 
could  not  be  detected  by  the  microscope,  and  also  that 
disease  may  exist  and  be  beyond  the  ken  of  even  the 
highest  optical  powers  yet  known. 

The  muscular  or  musculo-nervous  theory  was  maintained 
by  Duverney,  Rudolphi,  Beclard,  J.  Gue'rin,  and  subse- 
quently by  Delpech,  who  also  was  among  the  first  to  consider 
the  deformity  as  due  to  malformation  of  the  tarsal  bones. 
This  theory  supposes  an  unequal  action  of  the  muscles  and 
ligaments,  or  an  insufficient  development  of  the  calf  muscles, 
or  a  disease  of  the  nerve  centres.  Rudolphi  attributed  it 
to  intra-uterine  convulsions,  and  Chance  and  Little  are 
somewhat  inclined  to  support  this  view.  Guerin  stoutly 
supported  this  theory,  and  considered  club  foot  as  the 
result  of  convulsive  muscular  retraction  consecutive  to 
affection  of  the  central  nervous  system,  leaving,  sometimes, 
manifest  traces,  and  at  others,  none  whatever.  There  can 
be  no  doubt  that  where  other  deformities  are  present,  such 
as  spina  bifida,  &c,  club  foot  has  not  infrequently  been 
found  to  co-exist ;  but  on  the  other  hand,  many  foetuses 
with  considerable  destruction,  or  want  of  development  of 


TALIPES    OR    CLUB-FOOT.  151 

the  nervous  centres,  have  been  examined,  which  were  de- 
void of  club  foot.  Lannelongue  found  thirty-two  foetuses 
affected  with  congenital  defects  of  the  sexual  and  nervous 
centres,  of  which  only  four  had  club  foot.  Chaussieur 
relates  thirty-seven  cases  of  club  foot,  perfect  in  every  other 
respect,  so  that  the  nervous  theory  does  not  yet  appear  to 
be  sufficiently  established ;  and  though  the  muscles  are 
found  contracted  and  retracted  at  birth,  sufficiently  in 
severe  cases  to  have  produced  alteration  in  the  bones,  still 
this  muscular  contraction  may  be  secondary,  and  due  to 
mal-position  in  utero. 

The  theory  of  primitive  osseous  deformity  and  arrest  of 
development  has  had  weighty  names  in  its  support :  Scarpa, 
Broca,  Robin,  Lannelongue  and  Thorens  support  the  view 
of  original  osseous  deformity;  whereas  Meckel,  Geoffroy 
Saint-Hilaire,  Breschet,  and  Eschricht  upheld  the  view  of 
arrest  of  development,  and  thought  that  at  a  certain  period 
of  intra-uterine  life  the  infant's  feet  were  in  a  position  of 
varus,  and  there  can  be  but  little  doubt  but  that  this  is 
more  or  less  the  case ;  but  it  must  be  remembered  that  if 
this  explains  varus,  it  throws  no  light  on  the  other  forms  of 
club  foot. 

At  present  the  aetiology  of  the  subject  is  obscure,  and 
the  most  that  can  be  said  is  that  the  mechanical,  or  mal- 
position theory,  appears  to  be  the  more  probable,  though 
far  from  demonstrated.  I  am  inclined  to  think  that  the 
causes  of  club  feet  are  not  single  and  invariable,  and  there 
can  be  little  doubt  that  acquired  club  foot,  and  such  as  those 
of  which  all  experienced  men  must  have  had  the  oppor- 
tunity of  watching  the  development,  are  undoubtedly  due 
to  affections  of  the  nerves,  muscles,  fascia,  &c,  so  that,  for 
my  own  part,  I  see  no  difficulty  in  believing  that  if  the 
nervous  system  were  disturbed  during  intra-uterine  life,  and 
affected  the  muscles  acting   upon   the  foot,  these  might 


152  BODILY    DEFORMITIES. 

readily  induce  alterations  of  the  cartilaginous  predecessors 
of  the  tarsal  bones  in  the  congenital  forms. 


PES   EQUINO-VARUS. 

Synonyms. — German,  Klumfifuss ;  French,  Pied  bot 
varus. 

This  may  be  congenital  or  acquired.  The  former  is  the 
commonest  variety  of  club  foot.  Before  proceeding  to  the 
pathology  of  the  affection,  it  may  be  well  to  say  a  few 
words  regarding  the  normal  form  of  the  foetal  foot.  In  it 
the  plantar  arch  is  but  little  formed,  the  sole  of  the  foot  is 
turned  in,  and  the  anterior  part  slightly  adducted,  but  the 
peronei  are  capable  of  turning  the  sole  outwards.  To  dis- 
tinguish the  former  natural  position  from  slight  cases  of 
club  foot,  the  infant  should  be  placed  near  a  fire,  and  if  the 
foot  be  normal,  the  child  will  flex  the  thighs  upon  the  ab- 
domen, the  legs  upon  the  thighs,  and  turn  the  feet  out ; 
but  in  equino-varus,  it  will  not  be  able  to  evert  the  foot. 

In  this  deformity  the  anterior  part  of  the  foot  is  ad- 
ducted, the  inner  border  is  raised  upwards,  and  is  concave 
with  a  crease  at  the  transverse  tarsal  joint ;  the  external 
border  is  convex  and  looks  downwards.  The  heel  is  raised 
by  the  contracted  tendo-Achillis,  which  draws  the  os  calcis 
up  and  back,  and  is  generally  small.  In  severe  cases  the 
plantar  fascia  is  also  contracted,  forming  a  marked  cuta- 
neous crease  in  the  sole.  The  foot  is  generally  shorter 
and  broader,  and  very  commonly  the  great  toe  is  drawn  in- 
wards from  its  neighbour.  The  internal  malleolus  is  hidden, 
and  in  severe  cases  imperfectly  developed,  and  appears  to 
be  too  anteriorly  placed,  whereas  the  external  is  prominent 
and  appears  to  be  displaced  backwards.  On  the  dorsum, 
the  upper  portion  of  the  head  and  neck  of  the  astragalus 
are  seen  and  felt  to  project. 


PES    EQUINO    VARUS.  1 53 

In  neglected  varus,  that  is  to  say,  when  nothing  has  been 
done  for  the  deformity  until  the  patient  is  several  years  old 
or  reaches  the  adolescent  or  adult  stage,  progressive  changes 
have  occurred,  and  the  deformity  is  considerably  increased. 
In  the  plantar  region  and  inner  side  of  the  foot  two  deep 
grooves  are  observed,  one  longitudinal  and  the  other 
oblique.  The  former  is  placed  near  the  anterior  part  of 
the  foot,  and  the  latter  near  the  posterior,  the  longitudinal 
furrow  being  caused  by  the  fourth  and  fifth  metatarsal 
bones  folding  under  the  others.  In  walking,  the  subject 
rests  the  dorsal  surface  of  the  foot  on  the  ground,  the  skin 
becomes  thickened  and  bursas  form,  which  may  inflame 
and  cause  serious  trouble.  The  leg  muscles  waste,  and 
sometimes  the  tibia  rotates  on  the  vertical  axis,  so  that 
instead  of,  as  in  the  normal  condition,  a  vertical  line  pass- 
ing through  the  patella  and  prolonged  downwards  passing 
through  the  middle  of  the  anterior  tibial  tuberosity,  it 
passes  to  its-  outer  side.  In  other  cases  there  is  torsion  of 
the  tibia  rather  than  rotation,  so  that  its  upper  part  appears 
normally  placed,  whereas  its  lower  may  be  carried  either 
from  within  out,  or  from  behind  forwards;  or  from  without 
in,  and  from  before  backwards.  Scarpa  observed  the  for- 
mer mode  of  torsion,  in  which  the  internal  malleolus  was 
carried  forwards,  and  the  external  backwards.  In  the  latter 
mode  of  torsion  the  external  malleolus  is  in  front,  and  the 
internal  behind. 


CONGENITAL   EQUINO-VARUS. 

Pathological  Anatomy. — The  various  structures  form- 
ing the  foot  are  more  or  less  altered  in  well-marked  cases 
of  congenital  varus,  and  the  amount  of  deviation  from  the 
normal  will  depend  on  the  severity  of  the  case,  and  the 
length  of  time  it  has  remained  untreated ;  but  it  may  also 


154  BODILY    DEFORMITIES. 

be  due  to  mal-development  of  the  bones  and  other  struc- 
tures of  the  foot. 

Bones. — The  astragalus  is  in  a  state  of  extension,  and 
the  lower  surface  of  the  tibia  is  not  in  contact  with  its 
anterior  part,  but  only  with  the  posterior  part  of  its  articu- 
lating surface.  The  head  of  the  astragalus  appears  to  be 
carried  down,  in,  and  forwards,  and  its  neck  has  on  its 
outer  side  a  tubercle  separated  by  a  groove  from  the 
scaphoid  facet.  Its  upper  surface  is  smaller  than  natural, 
and  its  posterior  aspect  is  atrophied.  It  is  also  rotated 
on  an  antero-posterior  axis.  The  scaphoid  is  drawn  up,  in, 
and  back  by  the  tibials,  and  its  tuberosity  is  close  to, 
and  sometimes  articulates  with,  the  anterior  malleolus. 
The  cuboid  is  rotated  from  above  down,  and  from  within 
out,  and  its  upper  surface  becoming  anteroinferior,  rests  on 
the  ground  in  standing  or  walking.  The  os  calcis  is  also 
rotated  on  an  antero-posterior  axis  from  above  down,  and 
from  within  out,  and  both  its  anterior  and  posterior  extre- 
mities are  carried  inwards.  An  articular  surface,  divided 
into  three  facets  by  slight  creases,  is  found  at  the  junction 
of  its  internal  aspect  (now  become  superior)  with  its  superior 
surface  (now  become  antero-external).  The  external  facet 
corresponds  to  the  facets  on  the  external  malleolus  and 
under  surface  of  the  tibia,  the  middle  one  corresponds  to 
the  body  of  the  astragalus,  and  the  internal  one  is  in  con- 
tact with  the  infero-internal  part  of  the  head  of  the  astra- 
galus.    Its  tuberosity  is  turned  outwards. 

The  cuneiform,  metatarsals  and  phalanges  are  turned 
inwards,  and  the  metatarsals  tend  to  spread  out  towards 
their  heads,  so  as  to  broaden  the  anterior  part  of  the  foot. 
The  malleoli  are,  in  the  majority  of  recent  congenital  cases, 
quite  normal,  but  in  those  of  long  standing  the  inner 
malleolus  may,  through  pressure  from  the  scaphoid,  be 
arrested  in  its  growth.     The  fibula  is  often  slender,  and 


CONGENITAL    EQUINOVARUS. 


155 


bends  inwards  towards  the  tibia,  narrowing  the  interosseous 
interval. 

Articulations. — In  consequence  of  the  changed  posi- 
tion of  the  bones,  their  articular  relations  are  more  or  less 
altered,,  and  new  ones  are  also  formed.  The  condition  of 
the  tibio-astragaloid  joint  has  been  given,  and  that  of  the 
astragalo-scaphoid  is  drawn  inwards,  and  the  scaphoid 
being  partly  displaced  from  without  inwards,  the  anterior 
and  inner  part  of  the  foot  is  drawn  more  inwards  than  the 
outer.  The  astragal o-calcanean  articulation,  instead  of 
having  its  chief  axis  antero-posterior  is  transverse  to  the 
axis  of  the  leg,  and  this,  though 
allowing  the  ordinary  movements 
of  flexion  and  extension,  does 
not  usually  admit  of  abduction, 
adduction,  or  slight  rotation. 

Ligaments. — These  are  more 
contracted  than  in  the  normal 
infant  foot.  The  anterior  liga- 
ment passing  from  the  tibia  to 
the  astragalus  and  scaphoid  are 
thicker  and  shorter,  and  help  to 
fix  the  bones  in  the  deformed 
position.  Behind  the  joints  there 
exists  between  the  leg  bones  and 
the  calcis  a  capsule  which  sepa- 
rates into  two  parts,  and  an  interosseous  ligament  passing 
from  the  tibio-fibular  to  the  postero-tibial  surface  of  the 
calcis.  The  calcaneo-scaphoid  and  calcaneo-cuboid  liga- 
ments are  shortened  on  the  dorsal,  and  the  external  liga- 
ments are  elongated,  whilst  those  of  the  inner  and  plantar 
surface  are  shortened  and  thickened. 

Fascia. — The   plantar    fascia,    and   especially  its   inner 
and  middle  parts,  are  not  only  shortened  but  thickened, 


Fig.  64. — Diagram  of  a  normal 
foot  and  one  in  equino-varus,  to 
show  the  internal  deviation  of  the 
anterior  part.     (After  Sayre.) 


i56 


BODILY    DEFORMITIES. 


and  this,  with  the  retracted  muscles,  helps  considerably  to 
maintain  the  deformity.  In  severe  cases  there  are  subcu- 
taneous aponeurotic  and  fascial  bands,  which  vary  in 
different  cases,  and  must  be  divided  before  the  deformity 
can  be  thoroughly  corrected. 

Muscles. — At  birth  these  are  almost  always  healthy,  but 
if  allowed  to  remain  unused,  they  soon  atrophy,  and  the 
muscles  of  the  leg  waste,  giving  rise  to  the  atrophied  con- 
dition found  in  neglected  cases.  After  a  time  the  extensor 
muscles  may  also  become  atrophied  and  degenerated,  and 


TEND.   ACH. 


TIB.  ANT. 


Fig.  65. — Dissection  of  congenital  equino-varus.     Left  foot. 

this  change  is  a  fatty  and  not  a  fibrous  one.  Mr.  Adams 
has,  however,  recorded  one  case  of  hypertrophy  of  the  tibial 
muscles  and  of  the  inner  head  of  the  gastrocnemius,  the 
outer  head  being  rudimentary.  This  case  is,  of  course,  a 
rare  exception. 

Tendons. — The  tendons  of  the  tibialis  anticus,  posticus, 
flexor  longus  digitorum,  gastrocnemius  and  soleus  (tendo- 
Achillis)  are  shortened  in  equino-varus  and  altered  in 
direction.     The  tibialis  anticus  tendon   describes  a  curve 


CONGENITAL    EQUINO-VARUS.  157 

with  an  internal  concavity,  and  raises  the  lower  part  of  the 
deep  fascia  of  the  leg  and  anterior  annular  ligament  as  it 
crosses  the  tibia  at  a  higher  point  than  normal. 

The  tendon  of  the  tibialis  posticus  is  the  highest  and 
most  internal,  and  may  be  felt  behind  and  above  the 
internal  malleolus.  In  well  marked  cases  it  is  pulled  for- 
wards, but  in  milder  ones  it  passes  onwards  in  the  normal 
manner  to  its  insertion. 

The  tendon  of  the  Jlexor  longus  pollicis  is  deeply  placed 
beside  that  of  the  tibialis  posticus,  and  must  be  divided  in 
severe  cases  of  the  deformity. 

The  tendo-Achillis  is  shorter  and  narrower  than  normal, 
and  is  inserted  in  many  cases  more  to  the  inner  side  of  the 
calcanean  tuberosity.  It  may  appear  displaced  outwards 
through  the  oblique  position  of  the  os  calcis. 

The  tendons  of  the  peroneus  longus  and  brevis  are 
generally  displaced  somewhat  backwards  from  their  natural 
groove  on  the  outer  surface  of  the  os  calcis.  The  tendon 
of  the  proprius  pollicis  can  be  felt  more  plainly  than  is 
usual  along  the  upper  and  inner  part  of  the  dorsum  of  the 
foot,  and  the  tendon  of  the  extensor  communis  may  also  be 
felt  stretched  over  the  prominent  head  and  neck  of  the 
astragalus. 

The  muscles  of  the  sole  of  the  foot  are  atrophied,  the 
abductior  pollicis  is  generally  contracted,  and  can  be  felt 
to  the  inner  side  of  the  inner  piece  of  the  plantar  fascia, 
and  in  severe  cases  requires  division. 

The  vessels  and  nerves  are  shortened,  and  follow  the 
displacements  of  the  other  parts,  but  no  microscopic  nor 
histological  changes  have  yet  been  observed  in  congenital 
cases.  In  some  cases  of  congenital  equino-varus  there  are 
also  deformities  of  the  hip  or  the  knee. 

Such  are  the  usual  changes  in  congenital  equino-varus, 
but  in  neglected  cases,  where  the  sufferer  has  walked  much 


158  BODILY    DEFORMITIES. 

on  the  deformed  limb  and  has  been  allowed  to  reach  the 
adult  age,  further  changes,  as  might  be  expected,  occur, 
till  the  bones  become  more  or  less  atrophied,  their  tissues 
less  firm,  and  they  are  lighter  than  in  health. 

The  astragalus  has  its  inferior  surface  more  concave  in 
an  antero-posterior  direction  and  ends  in  two  projections, 
the  one  anterior  and  the  other  posterior.  Its  neck  is  a 
good  deal  elongated. 

The  os  calcis  increases  in  size  in  that  part  which  is  in 
front  of  the  astragaloid  and  above  the  cuboid  articulation. 
The  cuboid  facet  on  its  outer  side,  in  articulating  with  the 
cuboid,  projects  on  the  infero-external  border  of  the  foot. 

The  scaphoid  is  atrophied  and  compressed  in  its  inner 
half. 

The  cuboid  is  partially  displaced  from  the  calcaneus,  and 
drawn  in  and  downwards  and  its  external  surface  has 
become  convex. 

The fift h  metatarsal 'is  carried  downwards  and  articulates 
behind  with  the  external  surface  of  the  cuboid  which  is 
now  inferior,  and  this  articulation  is  placed  posteriorly  to 
those  of  the  other  metatarsals,  but  in  very  severe  cases  the 
fourth  metatarsal  joint  is  also  carried  a  little  backwards. 
This  arrangement  helps  to  form  talipes  plantaris,  or  cavus. 
The  ligaments  and  muscles  are  much  shortened  and  the 
latter  wasted,  and  bursse  are  developed  on  the  dorsum  and 
outer  surface  of  the  foot. 

Degrees  of  Deformity.— In  practice  we  may  arrange 
equino-varus  into  three  stages.  In  the  first,  in  which  the 
deformity  is  slightly  pronounced,  the  foot  is  easily  replaced 
in  its  natural  position,  that  is  to  say,  the  inversion  is  cor- 
rected and  the  heel  readily  brought  down.  In  the  second 
stage  or  degree,  but  little  effect  will  be  made  on  the  de- 
formity. In  the  third,  no  appreciable  effect  will  result  from 
attempts  at  manual  correction.     The  deformity  is  extremely 


CONGENITAL    EQUINO-VARUS.  I  59 

well  marked,  and  the  inner  border  of  the  foot  forms  an 
acute  angle  with  the  leg,  and  its  anterior  part  is  much  dis- 
placed inwards  from  its  posterior. 

The  movements  in  equino-varus  occur  chiefly  at  the  mid- 
tarsal  articulation,  and  consist  of  gliding  motions,  which 
are  so  combined  that  there  is,  on  the  one  part,  a  combina- 
tion of  flexion,  abduction,  and  rotation  of  the  sole  outwards, 
and,  on  the  other  hand,  a  combination  of  abduction,  exten- 
sion and  rotation  of  the  sole  inwards. 

Without  explanation  this  statement  would,  perhaps,  appear 
difficult  of  comprehension,  but  the  movements  tending  to 
produce  rotation  outwards  of  the  sole  are  checked  by  the 
contact  of  the  head  of  the  astragalus  with  the  upper  and 
outer  part  of  the  os  calcis,  and  also  by  the  ligaments  uniting 
the  os  calcis  posteriorly  to  the  tibia,  and  by  those  on  the 
inner  side  passing  from  the  tibia  to  the  astragalus,  and  from 
the  latter  to  the  scaphoid.  As  regards  the  second  series  ot 
movements  they  are  reduced  almost  to  nil,  for  the  deformity 
has  already  placed  the  foot  in  the  extreme  position  which 
these  movements  produce. 

ACQUIRED    EQUINO-VARUS. 

Causes.— These  may  be  :  i,  nervous  ;  2,  traumatic ;  3, 
articular.  The  nervous  causes  consist  of  two  different 
kinds,  which  give  rise  to  what  orthopaedic  surgeons  have 
called  the  spastic  or  active ;  and  the  paralytic  or  passive 
forms  of  the  deformity.  Spinal  sclerosis,  spasmodic  and 
convulsive  affections,  inflammation  or  injuries  of  the 
muscles  or  tendons,  may  all  lead  to  changes  in  the  form  of 
the  foot,  and  any  of  these  causes  may  give  rise  to  abnormal 
muscular  contraction  and  retraction.  On  the  other  hand, 
various  diseases  and  injuries  of  the  cord  or  nerve  trunks 
leading  to  paralysis  act  upon  the  abductors,  whereas  the 


l6o  BODILY    DEFORMITIES. 

former  causes  affect  the  adductors.  Among  the  causes 
leading  to  nervous  incompetence,  the  commonest  are  in- 
fantile paralysis  and  progressive  fatty  atrophy. 

The  traumatic  causes  are  fractures  in  the  neighbourhood 
of  joints,  dislocations,  sprains,  and  other  injuries  leading  to 
synovitis  of  the  tibio-astragaloid  or  tarsal  articulations. 

The  articular  causes  are  due  to  joint  inflammations 
whether  tubercular,  syphilitic,  rheumatic,  or  gouty.  I  have 
seen  instances  of  all  these  kinds  of  acquired  varus. 


PARALYTIC   EQUINO-VARUS. 

This  is  the  commonest  form  of  acquired  varus  and  is 
usually  due  to  a  sclerosis,  or  to  a  simple  atrophy  of  the 
anterior  spinal  columns,  and  especially  to  atrophic  changes 
in  the  cells  of  the  anterolateral  columns  and  the  anterior 
cornua.  The  deformity  is  produced  by  the  healthy 
muscles  predominating  over  those  paralysed,  which  are  the 
abductors  of  the  foot. 

I  need  not  here  occupy  valuable  space  by  going  into  the 
action  of  the  various  muscles  of  the  leg  and  foot,  but  may 
refer  those  interested  in  the  subject  to  the  first  volume  of 
my  work  on  "  Human  Morphology."  I  need  only  point 
out  here,  that  there  is  usually  little  difficulty  in  the  diagnosis, 
as  the  foot  is  generally  cold,  bluish,  or  purple,  the  leg 
muscles  wasted,  and  there  is  a  larger  subcutaneous  deposit 
of  fat  than  usual,  and  I  have  very  commonly  observed  a 
thickish  and  longish  collar  of  fatty  tissue  extending  two  or 
three  inches  along  the  lower  third  of  the  leg.  It  must  be 
borne  in  mind  that  spinal  caries  causing  mono-  or  para- 
plegia may  produce  this  deformity,  and  this  should  always 
be  inquired  into.  In  paralytic  cases  the  bones  will  almost 
always  be  found  wasted,  and  this  will  serve  to  differentiate 


PARALYTIC    EQUINO-VARUS.  l6l 

such  cases  from  those  due  to  progressive  fatty  atrophy  of 
the  muscles. 

Prognosis.— This  is  far  less  favourable  than  in  congenital, 
or  even  in  other  cases  of  acquired  varus,  and  the  reason 
is  obvious.  In  cases  of  any  standing,  when  all  hope  of 
an  improvement  of  the  disease  of  the  nervous  centres  is 
past,  and  when  electricity  fails  to  produce  any  hopeful 
muscular  reaction,  the  case,  as  regards  recovery  of  nerve 
power,  is  next  to  hopeless,  though  the  deformity  may  be 
rectified  and  kept  in  good  position  by  apparatus. 

Treatment. — The  indications  in  congenital  equino-varus, 
as  well  as  in  the  acquired  forms,  are  to  correct  the  deformity 
and  to  aid  the  limb  by  various  manual  and  surgical  means 
to  resume  its  functions.  I  need  only  state  with  regard  to 
paralytic  cases,  that  should  massage,  electricity,  and  proper 
apparatus  not  correct  or  improve  them,  and  tenotomy  be 
necessary,  extension  must  be  much  more  gradual  than  in 
ordinary  cases,  for  fear  of  converting  the  deformity  into  the 
opposite  one,  that  is  to  say,  a  varus  into  a  valgus,  &c.  It 
must  also  be  borne  in  mind  that  paralytic  limbs  must  be 
well  preserved  from  the  pressure  of  splints,  and  their  tem- 
perature must  also  be  thoroughly  maintained.  Frictions, 
massage,  a?id  electricity,  which  are  serviceable  in  some  of 
the  ordinary  cases,  are  especially  needful  in  the  paralytic 
forms. 

The  deformity  may  be  removed  in  various  ways,  but  it  is 
only  in  the  very  slight  cases  that  manipulations,  strappings, 
splints,  fixation  in  plaister  of  paris,&c,  will  lead  to  permanent 
results.  I  have  tried  them  all  and  have  been  disappointed, 
so  that  I  may  say  from  an  unusually  large  experience,  that 
in  the  great  majority  of  cases  it  is  but  wasting  time  to  try 
and  do  without  tenotonry,  so  I  will  at  once  proceed  to 
describe  it. 

In  equino-varus  the  tendons  producing  or  keeping  up 

M 


I  62  BODILY   DEFORMITIES. 

the  deformity,  and  therefore  those  that  require  division, 
have  already  been  given  •  but  I  may  here  re-state  that 
they  are  the  tibialis  anticus  in  front  of  the  malleolus,  the 
tibialis  posticus  and  flexor  longus  digitorum  behind  it  ; 
these  are  usually  divided  in  the  first  stage  of  the  operation, 
and  if  properly  divided  the  inversion  of  the  anterior  part  of 
the  foot  will  usually  yield.  After  about  ten  days,  in 
infants,  but  at  such  time  as  the  inversion  is  thoroughly 
corrected,  the  tendo-Achillis  will  require  division  ;  but  if  the 
plantar  fascia  and  abductor  pollicis  prevent  the  straightening 
of  the  foot,  these  must  be  divided  and  the  foot  straightened 
before  the  tendo-Achillis  is  cut.  If,  as  is  often  the  case, 
three  operations  are  necessary,  the  tendo-Achillis  must  be 
the  last  divided,  as  it  fixes  the  heel  and  thus  allows  the 
anterior  portion  of  the  foot  to  be  unfolded. 

Tenotomy.— The  patient  and  surgeon  being  in  con- 
venient positions,  an  assistant  should  fix  the  leg  with  his 
left  hand,  and  hold  the  anterior  part  of  the  foot  with  his 
right,  putting  the  tendons  fairly  on  the  stretch,  so  that  the 
surgeon  may  feel  them  with  his  left  fore  and  index  finger, 
while  he  passes  the  knife  beneath  them  and  saws  carefully 
towards  the  skin.  Directly  a  sharp  cracking  sound  is 
heard,  or  when  the  assistant  feels  all  resistance  to  be  gone, 
he  must  immediately  relax  the  foot,  the  surgeon  during  the 
whole  operation  keeping  the  knife  well  under  command,  so 
as  to  prevent  its  cutting  through  the  skin.  The  operation 
being  over,  a  small  pad  of  lint  is  placed  over  the  puncture, 
and  kept  in  place  by  a  narrow  piece  of  strapping,  the  foot 
is  then  bandaged  in  its  deformed  position  to  a  flexible 
splint  made  of  zinc,  tin,  or  sheet-iron,  well  padded,  and 
bent  to  the  shape  of  the  foot. 

In  the  first  stage  of  operative  treatment  the  tibialis  pos- 
ticus and  flexor  longus  digitorum  are  first  divided,  and 
then  the  tibialis  anticus.     In  dividing  the  former  a  sharp 


PARALYTIC    EQU1N0-VARUS. 


163 


tenotome  is  passed  between  the  posterior  surface  of  the 
tibia  and  the  tendons,  and  the  deep  fascia  well  opened. 
A  blunt  tenotome  is  then  passed  through  this  opening  well 
behind  the  tendons,  and  the  edge  of  the  tibia  being  used 
as  a  fulcrum,  and  the  left  forefinger  and  thumb  of  the 
surgeon  pressing  through  the  skin  on  the 
stretched  tendons  above  and  below  the  knife, 
they  will  generally  rapidly  give  way  if  a  gentle 
sawing  motion  be  used.  A  pad  is  at  once 
applied  and  kept  in  place  by  the  assistant's 
thumb.  To  divide  the  tibialis  anticus  a 
sharp  tenotome  is  passed  between  it  and 
the  anterior  tibial  artery,  passing  beneath  the 
tendon  and  cutting  towards  the  skin.  A 
pad  is  put  over  this,  a  bandage  is  then  applied 
over  the  foot  and  pads,  and  the  foot  is 
fastened  to  the  splint  as  already  directed. 
Care  must  be  taken  not  to  transfix  the  ten- 
dons ;  if  this  be  done  a  band  will  be  felt, 
and  it  must  be  divided.  The  anterior  and 
posterior  tibial  arteries  must  not  be  wounded.  Should 
the  case  be  a  relapsed  one,  where  previous  operations 
have  taken  place,  and  the  after-treatment  have  been  im- 
proper or  unsuccessful,  adhesions  will  have  formed  between 
the  tendons  and  their  sheaths,  and  the  use  of  the  blunt 
tenotome  in  various  directions,  especially  up-  and  down- 
wards, will  be  needed.  The  foot  should  also  be  well 
manipulated  immediately  after  the  tenotomy.  No  especial 
direction  is  needed  for  the  division  of  the  tendo-Achillis, 
except  to  avoid  passing  the  knife  too  far  in  the  direction  of 
the  posterior  tibial  artery.  For  division  of  the  plantar 
fascia  and  abductor  pollicis,  if  the  surgeon  recollect  or 
refresh  his  anatomy  and  take  care  not  to  pass  the  knife 
obliquely  down  and  in  towards  the  sole,  he  will  have  no 

M    2 


Fig.  66.  —  Sharp 
Tenotomes. 


164 


BODILY    DEFORMITIES. 


great  danger   or   difficulty   in  successfully   dividing  these 
structures. 

Accidents,  such  as  wound  of  the  posterior  or  anterior 
tibials,  or  of  the  plantar  arch,  inflammation  of  the  sheaths 
of  the  tendons,  subcutaneous  abscesses,  &c,  are  extremely 
rare,  but  should  they  occur  they  must  be  treated  on  ordi- 
nary surgical  principles.  For  wound  of  vessels,  a  firm 
graduated  pad  and  compress  must  be  applied,  and  no 
attempt  to  correct  the  deformity  must  be  made.     If  trau- 


Fig.  67. — Outer  view  of  my  universal        Fig.  00. — inner  view  of  the  same. 
Scarpa. 

matic  aneurism  result  it  may  be  cured  by  these  means, 
but  if  haemorrhage  be  severe  the  wounded  vessel  must  be 
sought  and  ligatured,  except  in  the  case  of  wound  of  the 
plantar  arch,  and  then  the  posterior  tibial,  and,  if  neces- 
sary, the  anterior  also,  must  be  secured.  I  once  saw  the 
tenotome  break  off  against  the  tibia.  This  necessitated 
enlargement  of  the  incision  to  extract  the  buried  frag- 
ment. 


PARALYTIC    EQUINO-VARUS. 


165 


"When  the  deformity  has  been  sufficiently  corrected  by 
tenotomy  and  the  use  of  the  flexible  splints  and  proper 
manipulations,  a  suitable  talipes  shoe  must  be  worn  for 
some  time.  The  form  which  I  have  found  extremely 
serviceable  in  private  practice,  is  figured  in  the  annexed 
drawing,  and  that  it  meets  almost  every  requirement,  is 
sufficiently  explained  by  the  fact  that  its  maker  has,  since 
I  first  drew  attention  to  it  in  the  Medical  Times  and 
Gazette,  sold  over  500  of  them  to  various   hospitals.     In 


Fig.  69. — Scarpa's  shoe  for  severe  cases.     New  form  :  The  patient  can  walk  in  this 


severe  cases  an  outside  toe-spring  is  attached,  so  that  the 
anterior  part  of  the  foot  can  be  still  further  everted.  A 
ball  and  socket  joint  or  rack-arrangement  worked  by  a  key 
is  adapted  above  the  ankle  on  the  outer  side.  Seeing  that  it 
answers  for  all  forms  of  ordinary  talipes  I  called  it  the 
Universal  Talipes  Shoe. 

After-treatment.— I  wish  it  thoroughly  to  be  under- 
stood, that  though  correction  by  tenotomy  and  splinting 
are  absolutely  essential  in  the  majority  of  cases,  it  is  in  the 


i66 


BODILY    DEFORMITIES. 


subsequent  proper  adjustment  of  splints,  frictions,  manipu- 
lations, massage,  &c,  of  the  foot  and  leg,  that  very  much 
of  the  success  of  these  cases  depend,  and  I  am  quite  sure 
that  if  the  tediousness  of  these  cases,  which  is  perhaps 
augmented  by  the  fact  that  very  few  cases  come  annually 
under  the  care  of  surgeons  at  general  hospitals,  were  less 
considered  by  them,  special  institutions  would  see  less  of 


Fig.  70. — Mr.  Baker's  scarpa  for  severe  cases  of  equino-varus.  A  A,  Straps  to 
firmly  fix  the  leg ;  B,  Ankle-strap  to  fix  heel ;  C,  Pad  to  be  placed  beneath  ;  D,  Plate 
attached  to  external  wing  ;  H,  Straps  ;  I,  Bar  for  toe-strap  ;  K,  Cog-wheel ;  S,  Large 
pad  to  be  used  inside  ;  M,  The  outer  wing. 

relapsed  cases.  My  motto  in  the  treatment  of  these  cases 
is,  that  more  attention  is  required  after  the  time  when  the 
foot  is  put  into  a  Scarpa  than  before. 

As  regards  the  age  at  which  tenotomy  should  be  done, 
and  with  reference  to  the  time  necessary  to  effect  a  cure  in 
most  cases  of  equino-varus,  I  would  say  that  as  a  rule  the' 
sooner  the  operation  is  undertaken  the  better,  provided  the 


PARALYTIC    EQUINO-VARUS. 


167 


child  or  patient  be  in  fairly  good  health;  but  there  is  no 
objection  to  allow  the  child  to  become  two  or  three  months 
old  if  necessary,  provided  extension  by  splints  be  carried 
on  during  the  interval,  as  this  lessens  the  difficulty  of  the 
treatment.  At  this  age  the  mother,  or  nurse,  has  less 
difficulty  in  preventing  the  splint  being  spoilt  by  the  urine. 


Fig.  71. — The  instrument  applied. 

An  ordinary  congenital  case  can  be  straightened  in  six 
weeks,  or  even  less,  but  it  is  not  safe  to  lose  sight  of  the 
patient,  and  instructions  should  be  given  to  bring  the  infant 
off  and  on  until  it  is  able  to  walk  and  be  placed  in  a  varus 
boot  or  support ;  and  it  should  then  also  be  watched  for 
months.     Any  tendency  to  inversion  of  the  toes  should  be 


1 68  BODILY   DEFORMITIES. 

corrected  by  an  instrument  passing  up  to  the  pelvis.  A 
night  instrument  must  also  be  worn  for  some  months,  and 
directions  given  to  the  mother  or  nurse,  as  to  the  various 


Fig.    72.  —  Equino  -  varus    shoe   for  Fig.  73. — Another  form  of 

severe  cases.    The  key  to  work  the  joint        Scarpa  with   movable  sole- 
at  ankle  is  shown.  plate. 

manipulations  necessary  to  keep  up  the  correct  position, 
and  to  give  power  and  tone  to  the  muscles  of  the  leg  and 
foot. 

UNTREATED    AND    RELAPSED  VARUS. 

These  cases  are  much  more  difficult  of  treatment, 
because  of  the  deformed  condition  of  the  bones  and  con- 
tracted state  of  the  ligaments,  and  also  because  of  the 
adhesions  which  have  formed  round  the  sheaths  of  the 
tendons.  In  the  severest  cases,  anchylosis  of  some  of  the 
tarsal  bones,  either  fibrous  or  osseous,  may  be  present.  In 
such  cases,  I  would  recommend  the  following  plan  of 
treatment :  First  to  divide  subcutaneously  all  tense  tendons, 
ligaments,  and  fasciae,  and  to  give  a  fair  trial  to  the  use  of 


UNTREATED    AND    RELAPSED   VARUS. 


169 


ordinary  orthopaedic  means,  such  as  properly  and  strongly 
constructed  talipes  shoes,  and  frequent  manipulations  under 
anaesthetics.  If  these  fail,  forcible  correction  of  the 
deformity  under  narcosis  should  be  attempted,  and  the 
foot  put   up  in  plaister  or  felt  in  the  improved  position. 


Figs.  74  and  75. — Untreated  equino-varus.     Anterior  and  posterior  views.     The  toes 

are  curled  up. 


The  splint  should  be  removed  in  about  three  weeks,  and 
further  powerful  manipulations  under  narcosis  should  again 
be  resorted  to,  and  the  foot  again  fixed  in  the  splint  for  a 
time.  If  in  from  two  to  three  months  but  little  benefit 
arise  from  this  mode  of  treatment,  I  should  proceed  to 


170  BODILY    DEFORMITIES. 

open  division,  or  tarsotomy,  i.e.  osteotomy,  or  osteectomy  of 
the  tarsal  bones.  The  preliminary  tenotomy  is  in  such  cases 
of  great  service,  and  necessitates  a  less  free  removal  of  bone 
and  a  smaller  wound. 

Tarsotomy.— Busch,  of  Bonn,  appears  to  have  been  the 
first  to  excise  a  portion  of  the  tarsus  in  cases  of  extreme 
equino-valgus.  Solly,  inspired  by  Little,  was  the  first 
English  surgeon  that  excised  the  cuboid  (1854)  and  perhaps 
fragments  of  neighbouring  bones  in  a  young  gentleman  of 
twenty-one,  affected  with  severe  congenital  varus.  The  re- 
sult was  not  so  favourable  as  Solly  expected.  Mr.  Richard 
Davy,  in  1875-6,  followed  by  Mr.  Davies-Colley,  published 
cases  of  excision  of  portions  of  the  tarsus  for  equino-varus 
and  equinus.  Lund,  of  Manchester,  had,  however,  excised 
the  astragalus  for  club-foot,  i.e.  severe  equinus,  in  1872. 
Bryant  and  some  Other  English  surgeons  have  also  published 
cases  of  this  operation.  In  Germany  this  method  has  found 
favour,  and  has  been  variously  modified;  but  in  France, 
Poinsot,  of  Bordeaux,  seems  to  be  the  only  surgeon  who  has 
adopted  the  plan,  though  I  have  heard  that  in  severe  cases 
it  has  found  a  few  followers  in  Paris. 

Premising  that  the  operation  is  very  rarely  indeed 
necessary  in  childhood,  and  reserving  it  for  the  neglected 
or  badly  relapsed  cases  of  adolescents  and  adults,  I  will 
say  a  few  words  as  to  the  operations  included  under  the 
head  of  tarsotomy.  Tarsotomy  comprises  several  opera- 
tions, such  as  excision  of  a  wedge  of  the  tarsus,  removal  of 
the  astragalus  alone,  or  of  the  cuboid,  with  open  wound ; 
but  I  am  not  aware  that  subcutaneous  linear  tarsotomy  has 
yet  been  practised,  though  I  think  it  would  be  compara- 
tively easy  to  avoid  damage  to  tendons,  vessels,  and  nerves, 
and  to  cut  through  the  bones  with  a  chisel ;  but  whether  an 
operation  not  excising  a  wedge  of  bone  would  be  successful 
remains  to  be  proved.     Anatomical  facts  seem  to  militate 


UNTREATED    AND    RELAPSED    VARUS.  Ijl 

against  it  if  unaccompanied  by  section  of  tendons  or  liga- 
ments. 

Poinsot  divides  this  operation  into  anterior  and  posterior. 
The  former  attacks  the  anterior  row  of  tarsal  bones,  and  the 
latter  the  posterior.  The  latter,  according  to  him,  consists 
in  excising  the  astragalus,  and  has  been  adopted  more 
especially  in  severe  cases  of  equinus.  The  anterior  opera- 
tion he  divides  into  partial  and  total.  In  the  former,  a 
single  bone  is  excised,  in  the  latter  a  large  portion  of  the 


Fig.  76. — Diagram  of  bony  section  in  tarsotomy  for  severe  equino-varus. 

tarsal  bones.  In  both  operations,  of  course,  several  joints 
are  interfered  with ;  but  with  care  there  should  be  no  seri- 
ous interference  with  the  tendons  and  their  sheaths. 

Cuneiform  Tarsotomy. — This  appears  to  have  been  first 
practised  by  Otto  Weber,  of  Heidelberg,  who  re-sected  a 
wedge-shaped  portion  of  the  cuboid  and  calcis.  Richard 
Davy  and  Davies-Colley  performed  the  operation  by  first 
extracting  the  cuboid,  then  with  the  bistoury,  saw,  and  lion- 
forceps  they  removed   portions    of  the   astragalus,  calcis, 


172  BODILY    DEFORMITIES. 

scaphoid,  and  cuneiforms,  and  the  cartilages  of  the  two  ex- 
ternal metatarsals.  The  incisions  for  these  operations  vary- 
according  to  their  extent,  being  curvilinear,  "f"-snaped,  form- 
ing flaps,  &c.  Bryant  made  use  of  the  X  incision,  but  his 
method  appears  to  have  the  disadvantage  of  dividing  the  soft 
parts  on  the  dorsum  of  the  foot.  Rupprecht  has  advised  a 
method  which  avoids  this  inconvenience.  He  incises  the 
skin  from  the  external  malleolus  to  the  base  of  the  fourth 
metatarsal.  The  extensor  digitorum  pedis  is  partly  detached 
and  thrown  forwards  and  inwards  with  its  tendons,  and  the 
periosteum  is  dissected  from  the  tarsal  bones  to  the  extent 
of  the  cutaneous  incision.  Two  retractors  keep  the  parts 
separate,  and  a  bistoury  passed  parallel  to  the  surface  of 
the  periosteum,  clears  as  much  of  the  tarsal  bones  as 
possible  without  opening  the  tibio-astragaloid  articulation. 
Two  converging  incisions  are  made  through  the  bones  with 
a  chisel,  the  one  parallel  with  the  ankle  joint,  the  other 
with  the  metatarso-phalangeal  articulations,  and  the  wedge- 
shaped  portion  of  the  tarsus  is  then  removed.  All  project- 
ing bony  spiculae,  or  roughnesses,  are  rounded  off*  with  the 
chisel  or  forceps,  and  the  foot  is  placed  in  a  splint  in  the 
corrected  position. 

Poinsot  operates  thus  : — A  T-shaped  incision,  of  which 
the  horizontal  limb  extends  from  the  external  malleolus  to 
the  head  of  the  fifth  metatarsal,  and  of  which  the  vertical 
branch  passes  across  the  dorsum  towards  the  scaphoid,  is 
made.  The  tendons  are  separated  from  the  bones  and 
drawn  inwards.  The  periosteum  is  then  incised  in  the  same 
direction  as  the  skin,  and  each  of  these  periosteal  flaps  are 
attached  to  the  skin  flaps  with  metallic  sutures,  which  help 
to  keep  the  wound  apart  during  the  rest  of  the  operation. 
Then  he  detaches  with  the  chisel  (he  prefers  a  saw)  an 
osseous  wedge,  the  lines  of  which  run  as  in  Rupprecht's 
operation.     The  base  of  the  wedge  will  then  be  external, 


UNTREATED    AND    RELAPSED    VARUS.  1 73 

and  ought  generally  to  measure  an  inch,  and  it  should  be 
broader  at  its  dorsal  than  at  its  plantar  surface.  He  advises 
that  the  cuboid  should  first  be  excised,  and  attempts  made  to 
rectify  the  deformity  before  proceeding  to  a  freer  osteotomy. 

Meusel  has  drawn  attention  to  a  practical  point,  which  it 
is  necessary  to  bear  in  mind,  concerning  the  amount  of  bone 
which  it  is  necessary  to  remove  to  correct  the  deformity. 
Before  operating  he  takes  a  plaister  model  of  the  foot,  and 
by  removing  portions  with  a  saw  from  this  cast  until  it  can 
be  straightened,  he  learns  how  much  it  is  necessary  to  re- 
move, so  as  to  bring  the  foot  into  a  proper  position.  This 
practice  had  been  previously  employed  in  cases  of  resections 
for  bony  anchylosis  of  the  larger  joints.  It  would  appear 
that  the  shape  of  the  wedge  removed  should  be  such  that 
it  should  have  two  faces,  one  external,  and  the  other 
towards  the  dorsum. 

Rydygier  has  recently  adopted  a  plan  by  which  a  good 
position  of  the  foot  can  be  obtained  with  slight  operative 
injury.  His  incision  begins  a  little  in  front  of  the  external 
malleolus,  and  passes  in  a  curve  with  its  convexity  down- 
wards towards  the  cuboid.  This  he  makes  at  once  down 
to  the  bone  as  no  important  parts  are  injured.  He  at  once 
obliquely  chisels  through,  from  without  inwards,  the  neck 
of  the  astragalus,  and  the  anterior  processes  of  the  calcis  a 
little  further  backwards,  and  by  stretching  the  ligamentous 
and  articular  attachments  of  these  bones  he  is  enabled  to 
remove  a  perpendicular  wedged-shaped  piece  from  Chopart's 
joint.  The  base  of  this  wedge  is  above  and  external.  He 
then  removes  a  horizontal  wedge,  with  its  base  external  from 
the  upper  part  of  the  anterior  process  of  the  calcis,  or  from 
the  under  part  of  the  astragalus,  or  from  both.  The  tendo- 
Achillis  is  divided  before  the  operation.  His  paper  shows 
drawings  taken  from  two  casts  made  after  the  operation, 
and  the  result  seems  good. 


174  BODILY    DEFORMITIES. 

• 

E.  Hahn  has  abandoned  linear  osteotomy  of  the  scaphoid 
and  head  of  the  astragalus  on  account  of  its  difficulty  and 
tedious  subsequent  treatment,  and  prefers  extirpation  of  the 
astragalus,  which  he  says  corrects  the  supination  and  plantar 
flexion  in  varus.  In  severe  cases  with  much  inversion,  a 
wedged-shaped  piece  of  the  anterior  processes  of  the  calcis 
must  be  removed,  and  by  doing  this  he  succeeded  in  cor- 
recting the  greatest  deformities.  He  thinks  that  Rydygier's 
method,  as  well  as  other  wedge-shaped  excisions,  especially 
those  which  open  the  tibio-astragaloid  joint,  are  apt  to  be 
followed  by  anchylosis  of  the  ankle,  thereby  doing  away 
with  many  advantages  of  the  operation. 

Mr.  McGill  of  Leeds,  at  the  Copenhagen  meeting  of  the 
International  Medical  Congress,  described  an  operation, 
which  is  substantially  that  of  Ogston  for  valgus,  applied  in 
the  case  of  varus.  He  made  a  longitudinal  incision  over 
the  cuboid  with  a  branch  over  the  dorsum  of  the  calcaneo- 
cuboid joint,  and  removed  a  more  or  less  extensive  bony 
wedge  according  to  the  severity  of  the  case.  The  cuboid 
and  calcis  were  then  pegged  together. 

Though  for  many  years  I  have  had  opportunities  of 
seeing  and  treating  cases  of  different  kinds  of  club-foot  in 
all  degrees  of  severity,  I  have  never  yet  had  occasion  to 
perform  a  tarsal  osteectomy,  because  patient  perseverance 
with  ordinary  modes  has  accomplished  what  was  desired. 
I  admit  that  the  treatment  of  these  bad  cases  is  long  and 
tiresome,  and  taxes  the  patience  of  both  surgeon  and 
sufferer,  but  a  method  I  have  recently  adopted  in  a  severe 
case  of  old  double  equino-varus  overcomes  these  objections. 
In  future  I  shall  not  hesitate  to  operate  on  any  suitable 
cases  in  which  tenotomy,  forcible  replacement,  massage, 
&c,  have  failed,  either  by  tarsotomy  or  preferentially  by  that 
mode  to  be  described  presently.  I  think  that  tarsotomy, 
as  I  have  already  suggested,  may  be  still  further  simplified 


UNTREATED    AND    RELAPSED    VARUS.  1 75 

so  that  its  risks  may  be  considerably  minimized,  but  I 
should  certainly  not  emulate  Mr.  Davy  in  operating  on  a 
child  sixteen  months  old,  though,  as  I  did  not  see  his  case 
before  operation,  I  can  express  no  opinion  about  it,  except 
that,  though  accustomed  to  see  severe  cases,  I  have  never 
seen  one  in  an  infant  that  would  not  yield  to  less  extreme 
measures.  My  experience  of  osteotomy  generally,  as  well 
as  of  many  other  large  surgical  proceedings,  without  the 
use  of  antiseptics,  would  not  lead  me  to  hesitate  in  per- 
forming non-antiseptic  tarsotomy,  though  I  am  not  at 
all  prejudiced  against  Listerian  precautions  for  those 
who  like  them,  but  I  see  no  need  to  adopt  them  until 
better  results  than  my  own  without,  are  shown  me  with 
them. 

Immediate  rectification  of  extreme  Equino  - 
Varus  by  multiple  Tenotomy  or  by  open  division. 
— Some  time  since  I  operated  on  a  boy  aged  eleven, 
the  subject  of  severe  double  neglected  equino-varus  by 
the  following  plans : — The  patient  being  anaesthetised 
and  Esmarch's  bandage  applied,  the  left  foot  was  firmly 
fixed  while  its  inner  border  was  well  stretched  by  an 
assistant,  and  the  usual  tenotomies  before  and  behind  the 
ankle  were  done.  Then  the  plantar  fascia,  abductor  pollicis, 
and  all  tense  fascial  bands  were  divided,  and  considerable 
force  used  to  rectify  the  deformity.  The  foot  was  imme- 
diately put  into  plaister  of  Paris  in  the  corrected  position ; 
and  when,  at  the  end  of  three  weeks,  the  plaister  was 
removed,  it  was  found  that  the  inversion,  though  much  im- 
proved, was  not  entirely  corrected,  I  divided  other  tense 
bands  and  the  tendo-Achillis.  Forcible  manipulations 
brought  the  foot  into  good  position,  though  the  heel  could 
not  be  brought  completely  down.  This  locking  at  the 
ankle  is  a  troublesome  feature  in  bad  cases  of  this  defor- 
mity, and  is  often  complicated  with  imperfectly  developed 


176 


BODILY    DEFORMITIES. 


os  calcis.     The  foot  was  again  put  up  in  plaister  and  fixed 
to  a  back  splint  with  rectangular  foot-piece. 

The  right  foot  was  operated  on  in  the  following  way. 
After  the  preliminary  tenotomies  an  incision,  two  inches 
long,  was  made  on  the  inner  and  lower  border  of  the  foot, 
and  joined  at  each  end  by  others  about  an  inch  long  across 
the  sole,  and  a  flap  of  skin  and  subcutaneous  tissue  reflected 
outwards.  The  abductor  pollicis  was  thus  exposed  and 
pulled  inwards,  and  the  tarsal  ligaments  which  prevented 
correction  of  the  deformity  were   divided.      The  plantar 


Figs.  77  and  78. — Double  congenital  neglected  equino-varus  before  and  after 

operation. 


fascia  was  then  divided  through  the  opening,  and  it  was 
found  that  the  inversion  could  be  almost  entirely  corrected. 
The  tendo-Achiilis  was  divided,  but  the  same  difficulty  in 
bringing  down  the  heel  was  encountered.  There  was  only 
slight  oozing  and  no  vessel  had  to  be  tied.  The  operation 
was  done,  as  is  my  wont,  without  Listerian  precautions. 
The  foot  was  put  up  in  a  flexible  metal  splint,  and  the 
wound  healed  without  rise  of  temperature,  though  the 
operation  was  done  without  antiseptic  precautions.  The 
above  figures  represent  the  case  before  and  after  opera- 
tion. 

Dr.  Phelps  of  Chateauguay,  New  York,  has  operated  by 
open  transverse  division  on  five  cases,  all  the  patients  being 
under  five  years  old.  He  divides  the  tendo-Achillis  and  then 


PES    VARUS.  177 

all  structures  down  to  the  bones  opposite  Chopart's  joint, 
and  the  only  parts  left  uncut  are  the  external  plantar  artery 
and  nerve.  He  read  a  paper  on  the  subject  at  the  Copen- 
hagen meeting  of  the  International  Medical  Congress. 

Dr.  W.  H.  Hingston,  of  Montreal,*  has  recently  pub- 
lished four  cases  of  severe  equino-varus  treated  by  trans- 
verse division  of  all  soft  parts  down  to  the  bones  and 
including  the  ligaments,  and  he  claims  good  results.  The 
operation  seems  to  me  an  unnecessarily  severe  one,  and  I 
should  fancy  that  the  large  scar  resulting  from  the  filling  in 
of  a  large  gaping  wound  would  give  trouble  in  the  future. 
If  open  division  be  necessary,  the  plan  I  have  suggested 
seems  far  preferable.  A  paper  was  presented  to  this  year's 
meeting  of  the  British  Medical  Association  at  Belfast  by 
Mr.  Phelps  on  "  The  Treatment  of  Equino-varus  by  open 
Incision,"  but  I  have  not  yet  seen  it. 

Amputation  by  Syme  or  Pirogoff's  method  in  the 
severest  paralytic  cases,  and  when  patient  trial  of  all  other 
means  have  failed,  and  if  the  patient  become  a  confirmed 
cripple,  may  become  necessary. 


PES    VARUS. 

This  deformity  is,  in  my  experience,  very  rare.  I  have  seen 
only  a  very  few  cases  of  true  varus  in  which  the  inner  edge 
of  the  foot  was  raised  and  the  sole  inverted  without  the 
heel  being  drawn  up.  I  am  quite  at  a  loss  to  understand 
why  various  English  and  foreign  writers  on  this  subject 
should  describe  ordinary  congenital  equino-varus  as  varus, 
seeing  that  they  all  acknowledge  that  the  heel  is  drawn  up 
and  that  the  tendo-Achillis  must  be  divided.  If  this  be  true 
varus,  I  see  no  need  for  their  special  chapters  on  equino- 
varus,  which  is    the   same  deformity.      The  treatment  of 

*  On  certain  forms  of  Club-foot.     Montreal.     1884. 

N 


178  BODILY    DEFORMITIES. 

severe  forms  of  varus  consists  in  dividing  the  same  tendons 
as  in  equino-varus,  with  the  exception  of  the  tendo-Achillis, 
and  the  after  treatment  is  conducted  on  similar  principles. 
This  deformity  may  be  congenital  or  acquired,  but  as 
already  said,  either  form  is  extremely  rare. 

Summary  of  Treatment. — In  the  milder  cases  of 
equino-varus  in  infants,  manipulations,  elastic  traction,  forci- 
ble correction  and  the  use  of  splints,  plaister  of  Paris,  or 
other  fixed  bandage,  or  Scarpa's  shoe,  may  be  efficient ;  but 
I  have  patiently  tried  them  all,  and,  in  the  vast  majority  of 
cases,  have  had  to  resort  to  tenotomy,  so  that  my  opinion 
is,  that  these  methods  usually  lead  to  disappointment  and 
waste  valuable  time,  for — providing  the  child  be  from  one 
to  two  months'  old,  and  in  good  health — tenotomy,  followed 
by  extension  in  flexible  metal  splints,  and  the  use  of  a 
proper  Scarpa,  combined  with  massage  twice  a  day,  yield 
perfect  results  even  in  the  severest  cases.  Any  form  of 
osteotomy  in  infants  and  young  children  is  utterly  indefen- 
sible and  unjustifiable  ;  for  even  supposing  the  primary 
change  be  in  the  cartilaginous  predecessors  of  the  tarsal 
bones,  these  are — at  the  age  alluded  to — plastic,  and  many 
thousands  of  cases  can  be  adduced  to  prove  the  curability 
of  the  deformity  without  recourse  to  so  unreasonably  severe 
a  measure  as  any  form  of  tarsotomy.  Moreover,  whether 
the  change  in  shape  and  position  of  the  astragalus,  &c,  be 
primary,  or  not,  it  is  abundantly  proven  to  those  of  large 
experience  in  Orthopaedic  surgery  that  the  tendons  are 
almost  always  shortened,  and  that  after  their  division  there 
is  usually  little  difficulty  in  correcting  the  malposition. 

In  neglected  or  badly  relapsed  cases  in  older  children,  or 
in  adults,  severer  measures  find  some  justification,  but 
even  in  these  cases  there  are  varying  degrees  of  severity. 
It  has  become  a  very  reprehensible  and  unscientific  fashion 
to  lump  such  cases  together,  and,  from  a  therapeutic  point 


PES    VARUS.  179 

of  view,  to  regard  tarsotomy  as  a  panacea.  I  have  had 
the  opportunity  of  seeing  a  few  cases  some  time  after  a 
bone  operation  had  been  performed  for  equino-varus,  and 
the  fact  that  these  cases  applied  for  relief,  combined  with 
the  imperfectly  corrected  position  which  the  feet  were 
in,  and  the  pain  and  inconvenience  complained  of  in 
walking,  even  with  a  stick,  seem  to  me  sufficient  evidence 
against  such  operations,  except  in  the  very  worst  cases.  I 
should  therefore  reserve  tarsotomy  as  a  last  resource,  after 
having  given  patient  trial  to  the  usually  successful  ortho- 
paedic methods,  and  as  certainly  preferable  to  amputation, 
which  can  only  be  excused  in  those  rare  cases  where  dorsal 
bursae  have  inflamed  and  ulcerated,  and  some  of  the  joints 
and  bones  are  diseased ;  or  in  extreme  paralytic  cases  in 
which  the  badly  nourished  skin  ulcerates  when  any  pressure 
is  applied,  and  the  patient  is  practically  bedridden. 

To  the  unprejudiced  mind  the  objections  to  orthopaedic 
plans  of  treatment  are  susceptible  of  the  following  explana- 
tions : — 1.  They  require  much  patient  perseverance  on  the 
part  of  the  surgeon  and  patient.  2.  Their  tediousness  and 
tiresomeness  necessitate  too  great  a  call  on  the  hospital 
time  of  most  general  surgeons.  3.  The  natural  desire  not  to 
let  orthopaedic  cases  pass  into  specially  trained  hands,  and  to 
cut  the  gordian  knot  by  a  severe  operation  (thereby  using 
surgical  means  to  which  they  are  accustomed),  rather  than 
patiently  learn  the  gentler  and — judging  from  what  I  have 
seen — more  efficacious  means  adopted  by  orthopaedists. 
These  are  the  days  of  les  folies  chirurgicales,  or,  as  Mr. 
Erichsen  has  said,  of  surgical  audacities,  or,  perhaps  more 
correctly,  as  Mr.  Jackson,  of  Sheffield,  truly  and  non- 
euphemistically  terms  many  surgical  procedures  of  the 
present  day,  of  surgical  atrocities ;  and  no  one  can  deny 
that  tarsal  osteotomies  in  infants  and  young  children 
richly  deserve   the   last   very  appropriate   name,   for   the 

N    2 


150  BODILY    DEFORMITIES. 

parents  are  ignorant,  the  child  helpless,  and  the  surgeon 
worse  than  rash  who  can  recommend  such  a  proceeding. 
Truly,  excessive  zeal  in  Listerism  will  have  something  to 
answer  for. 

Some  modern  oracles  tell  us  that  tenotomy  is  an  unscien- 
tific and  unjustifiable  operation,  because  other  and  more 
important  structures  than  the  tendons  are  involved ;  yet, 
these  same  wiseacres  recommend  forcible  reposition,  even 
to  the  extent  of  producing  fracture,  and  they  regard  tarso- 
tomy as  preferable  to  tenotomy.  The  logic  of  such  an 
argument  is  conspicuous  by  its  absence,  for  if  tenotomy  be 
improper  because  several  other  structures  besides  the  ten- 
dons are  affected,  why  are  only  the  bones  attacked,  or, 
rather,  in  the  case  of  infants,  the  flexible  cartilages,  when 
several  other  structures  concur  in  the  production  of  the 
deformity?  But,  really,  the  matter  is  placed  beyond  the 
need  of  argumentative  support  or  sophistical  refutation, 
for  every  orthopaedic  surgeon  of  experience  can  adduce 
hundreds  of  patients  to  prove  that  tenotomy,  followed  by 
regular,  patient,  and  attentive  subsequent  treatment,  will  so 
satisfactorily  correct  the  deformity  that,  in  a  large  number 
of  cases,  it  is  difficult  for  any  but  the  practised  eye  to  say 
if  club  foot  ever  existed.  It  is  fortunate  that  the  Vienna 
and  Dublin  Schools  do  not  agree  with  these  new-fangled 
views,  for  the  former  regards  bone  operations  on  children 
as  needless  mutilations ;  and  Professor  Stokes,  Mr.  Swan, 
and  Mr.  Ormsby,  of  Dublin,  rightly  hold  that  in  the  large 
majority  of  cases  in  children,  tenotomy,  followed  by  proper 
subsequent  treatment,  suffice  to  cure  the  deformity. 


iSi 


CHAPTER   XII. 


PES    EQUINO-VALGUS    AND    PES   VALGUS. 


Definition. — This  deformity  is  characterised  by  a  flat- 
tening of  the  tarsal  arch,  by  abduction  of  the  foot,  the 
anterior  part  of  which  is  turned  out ;  the  outer  side  is 
raised  and  the  inner  border  touches  the  ground.  The  de- 
formity is  the  opposite  to  varus,  but  almost  never  attains 
the  same  degree  of  severity,  though  in  some  cases  the  sole 
is  turned  back  as  well  as  outwards.  I  will  first  describe 
the  changes  in  the  congenital  and  subsequently  in  the 
acquired  forms. 

Synonyms. — French,  Pied  hot  valgus  ;  German,  Platt- 
Juss. 

Varieties. — It  may  be  congenital  or  acquired,  but  the 
former  is  very  rare,  and  most  of  the  congenital  cases  which 
I  have  seen  have  been,  in  reality, 
equino-valgus,  in  which  the  heel 
has  also  been  drawn  up ;  and  if  I 
may  judge  by  the  illustrations  in 
the  writings  of  various  authors 
their  cases  of  so-called  con- 
genital valgus  are  nearly  all  of 
the  same  kind.     Calcaneo-valgus 


also  occurs  as  a  congenital  de- 


FiG.  79. — Congenital  equino- 
valgus.     Left  foot. 


formity,  and  in  the  acquired  forms 

it  is  paralytic.    It  is  a  great  pity  for  the  clear  understanding 


152  BODILY    DEFORMITIES. 

of  the  subject  that  such  loose  nomenclature  and  description 
has  been  copied  from  one  book  to  another.  Milder  forms 
of  the  deformity  are  known  as  fiat  or  splay  foot  or  spurious 
valgus,  and  these  also  may  be  congenital,  but  are  much 
more  commonly  acquired.  They  are  best  considered  under 
the  more  correct  denomination  of  pes  planus,  and  will  be 
dealt  with  subsequently. 

CONGENITAL    EQUINO-VALGUS    AND    VALGUS. 

Degrees. — Three  degrees  have  been  established,  accord- 
ing to  the  amount  of  rotation  outwards  of  the  anterior  part 
of  the  foot,  and  these  may  be  termed  slight,  moderate,  and 
extreme.  In  the  first,  the  inner  portion  of  the  foot  is  de- 
pressed, and  the  outside  raised,  the  peronei  tendons  being 
not  tense,  and  the  foot  can  be  brought  easily  into  position. 
In  the  second,  the  scaphoid  tubercle  projects  under  the 
skin,  the  internal  malleolus  is  prominent,  and  the  sole 
turned  outwards.  The  peronei  behind  the  external  malleolus, 
and  the  extensor  digitorum  and  peroneus  tertius  on  the 
dorsum  are  tense.  In  the  third  form  the  patient  walks  upon 
the  inner  malleolus  and  scaphoid ;  bursas  form  over  the 
points  of  pressure,  and  the  tendons  are  very  tense.  The 
outer  half  of  the  foot  is  shortened  and  has  a  vertical  crease 
opposite  the  mid-tarsal  articulation,  and  the  sole  is  everted 
and  turned  backwards.  If  untreated,  congenital  equino- 
valgus  causes  greater  difficulty  and  more  pain  to  the  child 
in  walking  than  does  varus,  and  if  the  child  be  a  heavy 
one,  the  deformity  will  rapidly  increase. 

Pathological  Anatomy— Adams  has  shown  that  in 
this  deformity  the  changes  are  less,  though  carried  to  a 
more  advanced  stage,  than  in  congenital  varus,  i.e.,  equino- 
varus.  Of  the  bones  the  astragalus  is  somewhat  pushed 
forwards  and  downwards.     Tne  scaphoid  is  carried  out  and 


CONGENITAL    EQUINO-VALGUS    AND    VALGUS.  1 83 

up  and  at  the  same  time  rotated  on  its  antero-posterior 
axis,  so  that  its  inner  part  is  depressed  and  the  outer  raised, 
therefore  the  upper  part  of  the  astragaloid  head  does  not 
articulate  with  it.  The  cuboid  is  also  drawn  up  and  its 
outer  border  raised. 

The  os  calcis  is  rotated  on  an  antero-posterior  axis,  so  that 
the  concavity  formed  by  its  inferior  surface  is  directed 
downwards  instead  of  inwards,  and  its  tuberosity  looks  out- 
wards and  is  also  raised.  There  is  also  a  rotation  of  this 
bone  on  a  vertical  axis,  so  that  its  anterior  part  is  carried  in, 
and  its  posterior  outwards.  In  severe  cases  its  outer  surface 
articulates  with  the  external  malleolus.  The  metatarsal  bones 
and  phalanges  are  carried  up  and  outwards.  As  a  result 
of  these  bony  changes  the  plantar  arch  is  rendered  convex, 
and  three  projections  are  readily  felt  on  the  inner  side  of 
the  foot.  These  are,  i.  The  upper  part  of  the  head  of  the 
astragalus.  2.  The  inner  border  and  tubercle  of  the  sca- 
phoid. 3.  The  first  cuneiform.  Between  these  are  two 
depressions  due  to  stretching  of  the  ligaments  and  separa- 
tion of  the  bones.  In  less  severe  cases  the  cuneiform 
prominence  is  not  noticeable. 

Ligci7nents. — Those  on  the  internal  and  lower  side  of 
the  foot  are  stretched,  whereas  those  on  the  upper  surface 
are  retracted.  The  calcaneo-scaphoid  ligament  is  also 
much  stretched. 

Muscles.  — The  muscles  that  are  shortened  are  the  three 
peronei  and  the  extensor  longus  digitorum,  the  tendc- 
Achillis  participating  in  equino-valgus.  In  severe  cases  the 
abductor  minimi  digiti  and  extensor  pollicis  have  been 
found  contracted.  Some  writers  have  raised  a  doubt  as  to 
the  peroneus  longus  being  contracted  in  congenital  valgus, 
because  the  first  effect  of  its  contraction  is  to  produce 
a  hollow  sole,  i.e.,  pes  plantar  is  or  cavus  which  is  never 
found  in  congenital  valgus.     I  have  recently  operated  on  a 


184  BODILY    DEFORMITIES. 

girl  aged  three  at  the  Royal  Orthopaedic  Hospital,  the 
subject  of  congenital  valgus  of  the  pure  form,  and  on  the 
left  foot  the  peronei  and  extensor  longus  were  much  con- 
tracted, but  the  peronei  were  less  so  on  the  right  foot.  The 
illustration  in  the  section  on  congenital  valgus  shows  the 
deformity,  which,  in  foreshortening,  looks  as  if  the  heels 
were  drawn  up. 

The  tendons  are  not  much  altered  in  position  in  ordi- 
nary cases,  and  the  vessels  and  nerves  present  no  important 
alteration. 


PES    VALGUS    ACQUISITUS. 

Definition.— This  deformity  is  characterized  by  depres- 
sion of  the  arch  of  the  foot,  so  that  the  inner  side  of  the 
sole  touches  the  ground.  In  the  severer  forms  the  sole  is 
everted  and  may  be  turned  backwards. 

Causes,  Varieties,  and  Degrees. — This  distortion, 
which  consists  in  flattening  of  the  plantar  arch,  especially 
on  its  inner  side,  may  be  due  to  statical,  nervous,  traumatic, 
atonic,  rachitic,  and  articular  causes.  The  statical,  rachitic, 
and  paralytic  forms  are,  in  my  experience,  the  commonest. 
By  statical  I  mean  that  there  has  been  an  altered  axis  of 
bodily  pressure  towards  the  inner  side  of  the  foot,  and  if 
the  bones,  muscles,  or  ligaments  be  weak,  the  arch  will 
sooner  or  later  yield.  The  nervous  forms  include  the  para- 
lytic and  spasmodic  or  intermittent  varieties.  The  paralytic 
is  common  while  the  spasmodic  is  rare.  The  traumatic 
forms  may  be  due  to  fracture  or  dislocation  of  the  tibia, 
or  injury  of  the  tarsal,  or  metatarsal  joints,  or  to  cicatrices 
of  severe  injuries  and  burns.  Disease  of  the  ankle  or  neigh- 
bouring joints,  and  disease  due  to  tubercle,  gout,  rheu- 
matism, or  syphilis ;  or  secondary  to  inj  ury  of  these  parts, 
are  included  under  the  articular  causes.     The  statical  and 


PES    VALGUS    ACQU1  SITUS.  185 

atonic  forms,  the  latter  due  to  laxity  of  muscles  and  liga- 
ments, are  common  in  quickly  growing  adolescents,  espe- 
cially in  those  whose  bodies  are  unduly  heavy,  and  I  have 
frequently  seen  it  as  a  result  of  corpulency,  and  due, 
doubtless,  to  the  great  body  weight.  Acquired  valgus  may 
also  be  intermittent  or  permanent.  It  may  be  secondary  to 
knock-knee,  or  the  latter  may  follow  on  it.  Long  standing, 
or  the  carrying  of  heavy  weights,  or  sudden  great  exertion, 
may  cause  it.  The  mechanism  of  the  plantar  arches  and 
of  the  production  of  valgus  and  planus,  will  be  found  in 
the  chapter  on  pes  planus. 

Degrees. — It  is  difficult  to  get  exact  accounts  from 
patients,  but  from  many  inquiries,  and  from  having  had  the 
opportunity  of  seeing  this  affection  in  various  forms  and 
stages,  I  think  three  degrees  of  the  acquired  valgus  exist, 
viz.,  ordinary  or  slight  flat  foot,  the  medium,  and  the  severe  ; 
and  that  they  are  primarily  due  to  abnormal  direction  of  the 
pressure-weight  of  the  body  towards  the  inner  side  of  the 
foot.  This  abnormal  pressure  is  most  often  due  to  imperfect 
action  of  the  peroneus  longus,  and  this  action  may  be  in- 
termittent or  permanent. 

Pathological  Anatomy. — Except  in  rachitic  or  old 
paralytic  and  rheumatic  cases  the  bones  are  not  much 
altered  in  themselves  but  only  in  their  relative  position. 
The  astragalus  is  rotated  and  somewhat  displaced  down- 
wards, and  the  scaphoid  and  inner  cuneiform  move  in  the 
same  direction.  In  the  paralytic  forms  the  muscles,  and 
especially  the  tibialis  anticus,  are  degenerated.  The  instep 
is  flattened,  the  inner  malleolus  is  more  prominent  and 
nearer  the  ground,  and  in  severe  cases  there  is  a  space 
between  it  and  the  inner  side  of  the  astragalus.  The 
astragalus  and  scaphoid  project  upon  the  inner  side  of  the 
foot,  and  in  bad  cases  the  scaphoid  and  inner  cuneiform 
bear  the  pressure  of  the  foot,  and  bursae  become  developed. 


i86 


BODILY    DEFORMITIES. 


The  muscles  and  ligaments  upon  the  inner  side  of  the  joint 
are  stretched,  while  those  on  the  outer  become  secondarily 
contracted.  In  cases  of  long  standing  ankylosis  may 
occur. 

Various  theories  as  to  the  mode  of  production  of  flat 
foot  have  been  advanced.  Stromeyer*  thought  that  atony 
of  the  plantar  fascia  and  of  the  tarsal  ligaments  was  its 
cause.     Henkef  says  that  muscular  insufficiency  and  body- 


Figs.  80  and  81.  — Diagrams  of  the  external  aspect  of  a  normal,  and  severe  valgoid, 
foot-arch.  B  in  the  upper  figure  shows  the  highest  point  of  the  arch  with  the  calcaneo- 
cuboid ligament  beneath  it.  A  in  the  lower  figure  shows  the  prominence  of  the 
calcis  and  the  separation  between  it  and  the  cuboid.     (After  Lorenz.) 


pressure  are  the  factors  in  the  production  of  valgus  which 
is  a  pes  pronatus,  flexus,  and  rejlexus,  and  that  it  consists 
essentially  in  a  changed  position  of  the  joints  and  conse- 
quent alterations  in  the  shape  of  the  bones.  %  Hueter 
regarded  it  as  a  statical  distortion  produced  by  the  body 
weight,  causing    defective  development  of  the  bones,  but 

*  Beitrage  zur  operativen  Orthopadik,  1838. 

t  Zeitschft.  fur  rationelle  Medicin,  3rd  series,  Vol.  5,  1S59. 

t  Kritisches  iiber  Klump-und  Plattfuss.     Prager  Viertjahrschft,  B.  1. 

1875- 


PES    VALGUS    ACQUISITUS.  1 87 

Volkmann*  and  Reismann  have  shown  that  the  femoral 
neck  rises  and  the  foot-arch  forms  in  spite  of  this,  and  that 
it  is  therefore  very  improbable  that  valgus  should  be  pro- 
duced by  it. 

Reismannf  attributes  valgus  to  contraction,  first  of  the 
extensors,  and  then  of  the  pronators,  producing  a  pes 
pronatus  and  flexus,  and  states  that  a  sinking  of  the  arch 
is  impossible  on  account  of  the  construction  of  the  calcaneo- 
cuboid joint  ;  but  LorenzJ  in  his  excellent  essay,  and  also 
Volkmann,  have  shown  the  fallacy  of  this  view  which  is 
unsupported  by  any  pathological  examinations.  Lorenz 
supports  Henke's  view,  but  regards  sinking  of  the  external 
arch  from  pressure  as  the  primary  change,  and  the  pronation 
and  abduction  of  the  foot  as  later  secondary  results,  pro- 
duced by  a  sliding  away  of  the  inner  from  the  outer  arch. 
In  fact  the  arches  tend  to  become  placed  side  by  side  in- 
stead of  the  inner  resting,  as  in  the  normal  foot,  on  the 
outer. 

Hermann  von  Meyer  §  says,  that  this  form  of  flat  foot 
does  not  depend  upon  a  vertical  depression  of  the 
plantar  arch,  but  that  the  fundamental  phenomenon  is  a 
valgoid  position  of  the  remaining  portion  of  the  foot,  espe- 
cially of  the  calcaneus  to  the  astragalus,  and  that  associated 
with  this  fundamental  phenomenon  is  a  striking  secondary 
one  which  consists  in  a  bending  of  the  anterior  part  of 
the    foot    up    and    out    against    its    hinder    part.       The 

*  Ueber  den  Plattfuss  Kleiner  Kinder,  Central-Blatt  fur  Chirurgie, 
1881. 

f  Der  erworbene  Plattfuss.  Langenbeck's  Archiv,  B.  2,  Heft  3, 
1869  ;  and  Kritische  Bemerkungen  der  Lehre  von  der  Entstehung  des 
erworbenen  schmerzhaften  Plattiusses.  Same  Archiv,  B.  28,  H.  4, 
1883. 

X  Die  Lehre  vom  erworbenen  Plattfusse,  1883. 

§  Ursache  und  Mechanismus  der  Enstehung  des  erworbenen  Piatt, 
fusses,  1883. 


i88 


BODILY    DEFORMITIES'. 


cause  of  these  appearances  is  not  to  be  sought  in  the 
weakening  of  the  plantar  ligaments,  but  the  originating 
source  for  the  transformation  of  a  normal  into  a  flat  foot 


Fig.  82. — Showing  the  skeleton  of  a  convex  or  canoe-shaped  sole  of  an  extreme 
valgus.  (After  Lorenz.)  1.  A  new  joint  between  the  fibula  and  calcis.  The  cuboid 
touches  the  ground  but  the  calcis  and  metatarsal  are  raised. 


Fig.  83 — Inner  view  of  the  bones  of  a  severe  valgus.  1,  Scaphoid  tubercle  ; 
2,  Astragalus  ;  3,  Calcis  ;  4,  Cuboid  ;  5,  Inner  metatarsal  which  appears  shortened. 
The  plantar  calcaneo-scaphoid  ligament  is  stretched.     (After  Lorenz.) 

resides  in  a  rotation  of  the  astragalus  inwards,  which  is,  of 
course,  assisted  by  the  pressure  of  the  ground  in  standing 


PES    VALGUS    ACQUISITUS. 


189 


and  walking.  This  valgoid  condition,  which  next  affects 
the  calcis,  is  due  to  the  rotation  altering  the  position  of  the 
line  of  gravity  inwards  from  the  line  of  the  great  toe, 
and  the  bending  is  to  be  attributed  to  the  raising  of  the 
posterior  process  of  the  os  calcis  up  and  out,  through  the 
traction  which  the  rotation  of  the  astragalus  exercises  on 
the  calcaneo-fibular  ligaments.  The  changes  in  the  re- 
lative positions  of  the  tarsal  bones  are  not  caused  and 
gradually  increased  through  weakening  of  the  ligaments, 
but  through  pressure-atrophy  of  the  bones  ;  and  the  two 


Fig.  84.— Inner  view  of  severe  right  valgus.     1,  Inner  malleolus  ;   2,  Inner  part  of 
head  of  astragalus ;  3,  Scaphoid  tubercle. 

following  false  joints,  which  are  found  in  the  highest  degrees 
of  the  deformity,  are  caused  by  the  two  elements  producing 
flat  foot.  The  new  or  false  joint  between  the  calcis  and 
fibula  is  caused  by  the  valgoid  position  of  the  latter,  and  the 
joint  between  the  scaphoid  and  upper  surface  of  the  neck 
of  the  astragalus  is  due  to  a  bending  or  flattening,  and 
ultimate  convexity,  of  the  sole. 

Paralytic  Valgus. — The  paralytic  varieties  are  of  prac- 
tical  importance.      They  may  be  produced  in  two  ways 
1.  By  paralysis  of  the  foot  adductors.     2.  Through  para- 
lysis of  the   peroneus  longus.     In  the  former,  the  tibialis 


19°  BODILY    DEFORMITIES. 

anticus  and  posticus,  and  especially  the  latter,  are  the 
muscles  chiefly  affected,  and  the  abductors  of  the  foot, 
the  peronei,  are  then  free  to  act  and  place  the  foot 
in  abduction ;  and  the  peroneus  longus  being  no  longer 
counter-balanced  by  the  tibialis  anticus,  increases  the  con- 
cavity of  the  plantar  arch,  so  that  a  valgo-cavus  results. 
In  paralysis  of  the  peroneus  longus  a  form  of  flat  foot 
termed  painful  valgus  results,  and  a  peculiar  condition 
of  it  in  a  state  of  abduction,  combined  with  effacement  of 
the  plantar  arch,  and  tarsalgia,  results.     Guerin  thought  this 


fe)D. 


Fig.  85. — Diagram  of  bad  valgus  from  above,  showing  the  altered  axes  of  the 
tarsals,  metatarsals  and  phalanges,  and  the  projection  of  the  head  of  the  astragalus. 


variety  was  due  to  relaxation  of  the  tarsal  ligaments,  which 
caused  pain  and  reflex  contraction  of  the  peronei  and  ex- 
tensor communis,  and  advised  tenotomy.  Duchenne 
showed  by  faradization  that  this  affection  was  due  to  para- 
lysis of  the  peroneus  longus,  and  that  if  the  peroneus 
brevis  and  tertius  and  extensor  communis  be  contracted, 
this  is  purely  reflex.  Seeing  that  the  first  effect  of  con- 
traction of  the  peroneus  longus  is  to  increase  the  convexity 
of  the  arch,  it  seems  difficult  to  believe  that  this  form  of 
valgus  is  due  solely  to  the  contraction  of  that  muscle. 
Symptoms  and  External  Appearances.— In    most 


PES    VALGUS    ACQUISITUS.  191 

cases  of  this  deformity  the  patient  applies  because  of  pain 
and  difficulty  in  walking,  and  inability  to  stand  or  go  any 
distance.  There  will  be  pain  towards  the  inner  side  and 
sole  of  the  foot,  and  in  cases  of  any  standing  the  muscles 
on  the  outer  side,  the  peronei  and  extensor  longus  digi- 
torum,  will  be  found  prominent  and  secondarily  contracted. 
This  phenomenon  is  a  reflex  one,  and  such  cases  must  not 
be  mistaken  for  primary  spasmodic  or  spastic  valgus,  which 
is  a  very  rare  affection.  On  endeavouring  to  rectify  the 
foot  with  the  hands,  the  patient  will  complain  of  pain,  and 
refer  it  to  the  region  of  the  muscles  just  mentioned.  The 
impression  of  the  sole  in  such  cases  is  represented  in  a 
subsequent  figure.  The  walk  is  characteristic,  the  subject 
coming  down  on  the  inner  part  of  the  foot, 
with,  in  severe  cases,  the  knees  in  a  flexed 
valgoid  position.  There  is  always  a  halting 
or  lameness  in  the  gait. 

In  ordinary  flat  foot  the  plantar  arch  is 
considerably  depressed,  and  the  malleoli  are 
sunken  and  prominent,  especially  the  inner. 
The  foot  is  prone  to  foetid  perspiration,  and 
the  skin  on  its  inner  side  is  thin,  but  on 
the  outer  thickened.  Pains  along  the  course 
of  the  peronei  and  about  the  external  fig.  86.— im- 
malleolus,  and   across  the  instep,  are  com-  Pressi°n   of    a 

-1  normal         sole. 

plained  of,   and  often  produced  on  pressure.   The  dotted  line 
If  pressure  be  made  on  the  plantar  surface  sho7* the  °uteT 

-r  *  and    inner    bor- 

or  on  the  metatarso-phalangeal  articulation  ders  of  the  foot. 
of  the  great  toe  while  the  foot  is  extended, 
and  the  patient  be  willing  to  resist  this  pressure,  he  will  be 
able  to  do  so.  If  the  patient  be  sitting  or  lying  with  the 
foot  extended,  it  will  have  a  tendency  towards  varus. 
This  is  caused  by  the  tibialis  posticus,  gastrocnemius, 
and   soleus,   which,   being    extensors   and   adductors,   are 


[92  BODILY   DEFORMITIES. 

incapable  of  producing  rectilinear  extension  on  account  of 
paresis  of  the  peroneus  longus.  When  the  patient  is  stand- 
ing, his  foot  flattens  out  on  the  ground,  the  instep  has 
almost  disappeared,  and  he  cannot  raise  himself  on  his 
toes.  In  going  up  stairs  the  whole  of  the  foot  is  placed 
upon  each  step,  instead  of  the  anterior  portion,  as  with 
normal  feet ;  and  in  walking,  the  foot  does  not  touch  the 
ground  from  heel  to  toes,  but  by  the  whole  sole. 

In  the  second  or  medium  degree  of  the  deformity  the 
pains  increase,  and  painful  points  in  the  region  of  the 
peronei,  at  the  neck  of  the  astragalus,  and  near  the  internal 
malleolus,  and  at  the  base  of  the  first  and  fifth  metatarsals, 
may  exist,  but  ordinarily  these  are  only  found  in  the  third 
degree,  the  commonest  seat  of  pain  being  that  to  the 
inner  and  lower  side  of  the  astragalus. 

In  the  third  degree  pain  is  much  increased.  On  walking 
there  is  a  feeling  of  heaviness  and  creeping  sensations  in 
the  sole,  which  are  due  to  compression  of  the  plantar 
nerves.  The  painful  points  are  more  numerous  and  the 
deformity  is  permanent.  The  sub-astragaloid  painful  spot 
is  a  little  in  front  of  the  external  malleolus,  on  a  level  with 
the  calcaneo-astragaloid  articulation,  and  is  due  to  pressure 
between  the  articular  surfaces  and  bruising  of  the  inter- 
osseous ligaments.  The  pain  about  the  head  and  neck  of 
the  astragalus  is  due  to  stretching  of  the  astragalo-scaphoid 
ligament,  and  to  the  depression  and  rotation  of  the  astra- 
galus. The  peroneal  pain  is  along  the  course  of  the 
peroneus  longus.  The  pain  at  the  base  of  the  first  meta- 
tarsal is  due  to  the  action  of  the  tibialis  anticus,  unbalanced 
by  that  of  the  peroneus  longus,  and  this  abnormal  action 
tends  to  raise  the  first  cuneiform  and  metatarsal  bones, 
producing  stretching  and  frictions  which  cause  pain. 
There  is  another  painful  spot  at  the  outer  side  of  the  joint 
in  the  neighbourhood  of  the  calcaneo- cuboid  joint,   and 


PES    VALGUS    ACQUISITUS.  1 93 

this  is  produced  by  the  stretching  of  the  calcaneo-cuboid 
ligament  through  effacement  of  the  plantar  arch. 

This  form  of  flat  foot,  if  not  remedied,  passes  on  to 
abduction  of  the  anterior  portion  of  the  foot  and  eversion 
of  the  sole,  and  this  is  due  to  impotence  of  the  peroneus 
longus,  which  can  no  longer  keep  the  inner  part  of  the  sole 
applied  to  the  ground,  so  that  an  external  rotation  occurs 
at  the  mid-tarsal  joint,  and  this  is  increased  by  the  reflex 
contraction  of  the  peroneus  brevis,  tertius,  and  extensor 
communis.  In  the  second  degree  the  symptoms  may  in- 
termit, i.e.,  when  resting  or  simply  standing,  the  pain  and 
the  deformity  diminish,  and  after  long  standing  and  walk- 
ing reappear.  If  the  patient  be  told  to  stand,  his  foot  will 
be  observed  to  be  simply  flat ;  but  long  standing  or  walk- 
ing bring  on  the  pains,  and  the  foot  is  in  marked  valgus, 
and  if  any  great  exercise  (which  such  cases  can  rarely  take) 
have  been  indulged  in  the  pain  is  much  increased,  and  I 
have  known  cases  which  ended  in  tarsal  synovitis.  In  the 
third  and  pei'mcment  form  the  deformity  remains  whether 
the  patient  be  resting  or  not,  and  this  is  due  to  the  per- 
manent contraction,  and,  in  old  cases,  retraction  of  the 
peroneus  brevis,  tertius,  and  extensor  communis  digitorum. 

There  can  be  little  doubt  that,  in  time,  physiology  and 
pathology  may  sufficiently  explain  a  large  part  of  this  class 
of  cases  by  referring  it  to  temporary,  and  then  final  para- 
lysis of  the  peroneus  longus,  whether  primary  or  secondary. 
The  action  of  this  muscle  is  to  depress  the  internal  border 
of  the  anterior  part  of  the  foot,  to  increase  the  concavity 
of  the  plantar  arch,  to  keep  the  first  metatarsal  depressed 
during  extension  of  the  foot,  and  also  to  raise  its  external 
border,  and  these  are  the  very  actions  which  are  disturbed 
in  cases  of  severe  valgus. 

There  is  a  symptom  to  which  I  will    draw  attention, 
having  noticed    it   in   many  instances  of  severe  acquired 

o 


194  BODILY    DEFORMITIES. 

valgus,  and  this  is  a  pain  and  stiffness  at  the  metatarso- 
phalangeal joint  of  the  great  toe,  and  flattening  of  the  ball 
of  the  toe.    Sometimes  this  is  the  first  thing  noticed  by  the 
patient,  and  the  tarsal  pains  appear  subsequently.     Nearly 
all  cases  of  acquired  valgus  occur  in  those  having  long  feet. 
Mode  of  Production. — From  a  consideration  of  the 
foregoing    facts    it    would    appear   that    acquired   valgus 
originates   in   the    following  way  : — First,   some   pressure, 
abnormal  either  in  direction  or  extent,  causes  a  stretching 
and  exhaustion  of  the  muscles,  ligaments,  fascia,  and  ten- 
dons of  the  sole ;  then  the  outer  arch  becomes  depressed 
and  the  inner  glides    down    and    in    from    it,  tending   to 
become  parallel  with  it.     The  astragalus  is  pushed  down, 
stretching  the  internal  lateral    and    tibio-astragaloid    liga- 
ments, and  carrying  with   it  the  scaphoid,  cuneiforms,  and 
inner   metatarsals  ;   the  astragalo-scaphoid  joint  becomes 
loosened  and  gaping  at  its  inner  border,  and  the  inner  part 
of  the  articular  facet  of  the  astragalus  is  no  longer  in  con- 
tact with  the  scaphoid.     Its  cartilage  becomes  absorbed, 
and  the  inner  portion  of  its  head  projects  internally,  and 
forms   an   obvious   prominence.      The  ligaments    on   the 
plantar  aspect  of  the  joints  become  stretched,  and  the  bones 
parted   from    each    other   in    this   situation,   while  at   the 
dorsal  aspect  they  are  pressed  together,  and  impeded  growth 
or  absorption  results.     In  the  severest  cases,  not  only  does 
the  head  of  the  astragalus  touch  the  ground,  but  the  sole 
divides  at  the  mid-tarsal  joint  into  an  anterior  and  posterior 
•  part,  the  former  being  the  walking  sole,  while  the  latter,  con- 
sisting of  the  os  calcis  and  the  astragalus,    is    drawn    up 
posteriorly,  so  that  the  calcanean  tuberosity  is  raised  an  inch 
from  the  ground,  and  this  part  of  the  sole  does  not  touch 
the  soil.      Soon  the  bones  become  permanently  fixed  in 
this  position,  and  the  canoe-shaped  foot  is  produced.     In 
the  earlier  stages,  the  deformity  may  disappear  after  resting, 


PES    VALGUS    ACQUISITUS.  1 95 

or  on  raising  the  foot,  but  later  on  anchylosis  results,  and 
the  malady  becomes  permanent. 

Diagnosis.— This  consists  in  serological  differentiation, 
and  the  history  of  the  case  and  symptoms  are  generally 
enough  for  this  purpose.  In  slight  degrees,  and  especially 
if  occurring  early  in  life,  it  may  be  confounded  with  the 
congenital  form  of  valgus.  I  use  the  term  form  advisedly, 
to  differentiate  a  tendency  to  slight  flat  foot  at  birth,  from 
the  rare  forms  of  congenital  pes  valgus  proper.  In  con- 
genital valgus  the  deformity  is  almost  always  double  and  the 
peroneus  longus  has  a  normal  faradaic  reaction.  Acquired 
flat  foot,  on  the  other  hand,  may  be  single  or  double. 
Painful  flat  foot  may  be  confounded  with  tarsalgia,  due  to 
joint  disease,  and  in  these  cases  the  deformity  is  secondary. 
I  have  recently  operated  at  the  London  Hospital  on  a  tall 
young  woman  of  twenty,  with  badly  marked  double  valgus. 
She  had  most  of  the  painful  spots  referred  to,  the  feet 
sweated,  and  there  was  a  doughy  fulness  in  the  position  of 
the  astragalo-scaphoid  and  scapho-cuneiform  joints,  which 
I  regarded  as  secondary.  Tenotomy  of  the  peronei  and 
extensor  longus  digitorum  was  done,  and  she  was  kept  in 
bed  for  one  month,  when  she  was  allowed  to  walk  the 
ward  in  her  boots  and  supports.  On  the  second  day  she 
complained  of  great  pain,  and  there  was  a  good  deal  of 
doughy  swelling  and  tenderness  over  these  joints,  and  I 
began  to  think  that  hers  was  an  instance  of  valgus  and 
reflex  muscular  contraction  secondary  to  joint  disease ;  but 
two  days'  rest,  with  evaporating  lotions,  completely  cured 
her,  and  she  walked  well,  leaving  the  hospital  in  a  few 
days.  In  older  people  the  dry  forms  of  arthritis  may  also 
give  rise  to  diagnostic  difficulty.  Gosselin  records  a  case 
of  tarsalgia  in  which  post-mortem  examination  showed 
erosions,  and  disappearance  of  the  cartilages,  of  the  cal- 
caneocuboid and  astragalo-scaphoid  joints,  and  attributes 

o  2 


196  BODILY    DEFORMITIES. 

the  tarsalgia  of  adults  to  these  changes ;  but  the  severe 
forms  of  valgus,  long  continued,  will  lead  to  joint  de- 
formity, and  may  cause  cartilaginous  erosion.  It  should 
be  recollected  that  incipient  stages  of  tarsal  and  metatarsal 
bone  and  joint  disease,  and  of  perforating  ulcer,  may  give 
rise  to  diagnostic  difficulty,  as  the  foot  is  more  or  less  flat- 
tened in  such  cases,  and  also  that  neurarthropathies,  such 
as  Charcot's  joint  disease,  may  also  simulate  the  symptoms 
of  valgus.  The  pathology  and  differential  diagnostic  signs 
of  these  are  still  very  doubtful.  It  must  be  borne  in  mind 
that  after  resting,  or  even  in  raising  the  foot  from  the  ground, 
the  flattened  condition  may  disappear,  except  in  the  worst 
cases. 

Prognosis.— If  valgus  due  to  paresis  of  the  peroneus 
longus  be  seen  in  an  early  stage  it  is  easy  to  cure,  but  in 
the  later  stages  it  is  less  easy,  unless  sufficient  power  be 
left  in  the  muscle  to  completely  recover  its  functions.  If 
joint  mischief  have  arisen  the  prognosis  is,  of  course,  more 
serious,  and  this  may  occur  in  neglected  cases.  In  ordinary 
cases  of  acquired  valgus  tenotomy,  massage,  and  proper 
apparatus  will  correct  the  deformity ;  but  if  anchylosis  have 
occurred,  and  pain  and  difficult  progression  exist,  tarsotomy 
may  prove  successful. 

VALGUS    ANKLE. 

This  condition,  known  popularly  as  weak  ankles,  is  not 
alluded  to  in  surgical  works,  and  consists  in  a  laxity  of  the 
internal  lateral  ligament  and  consequent  bulging  of  the 
internal  malleolus,  with  a  tendency  to  the  formation  of 
valgus.  It  may  exist  quite  independently  of  the  latter,  and 
is  not  uncommon  in  infantile  paralysis  of  the  lower  limbs, 
and  in  cases  where  the  arch  of  the  foot  is  increased  and 
the    plantar   fascia   tense.      In    some   cases   the   internal 


VALGUS    ANKLE.  I  97 

malleolus  is  overgrown  laterally,  and  a  condition  somewhat 
similar  to  the  projection  of  the  internal  condyle  in  atonic 
genu  valgum  results.  I  have  seen  small  bony  spicules  in 
the  neighbourhood  of  the  inner  ankle,  reminding  me  of 
those  met  with  in  the  tibia,  and  occasionally  on  the  internal 
tuberosity  of  the  femur.  If  unchecked,  some  of  these  cases 
may  pass,  mechanically,  into  valgus. 

Symptoms. — The  deformity  is  obvious,  and  occurs 
usually  in  quickly  growing  children  or  adolescents  with  lax 
fibre.  The  ankles  knock  together  in  walking,  and  this, 
with  the  wearing  away  of  the  boots  where  the  ankles  rub 
each  other  in  walking,  are  noticed  and  complained  of.  The 
patient  is  very  apt  to  tread  or  slip  over  to  the  inner  side  of 
the  foot,  and  sometimes  this  gives  rise  to  severe  sprains 
and,  in  two  or  three  cases  I  know  of,  a  Pott's  fracture  was 
thus  produced. 

Treatment. — This  consists  in  giving  firm  support  to 
the  joint  on  its  inner  side  by  good  elastic  anklets,  and  by 
the  wearing  of  a  boot  and  support  with  a  properly  adjusted 
T-strap.  All  prolonged  efforts  of  standing  and  walking 
must  be  avoided,  and  the  joint  strengthened  by  massage, 
frictions,  &c. 


CONGENITAL   VALGUS. 

In  this  deformity  the  sole  of  the  foot  is  flattened,  the 
inner  margin  touches  the  ground,  the  outer  being  raised, 
and  the  anterior  portion  of  the  foot  is  everted.  In  severe 
cases  the  sole  is  turned  out  and  back.  Pure  congenital 
valgus  is,  as  previously  stated,  rare  in  my  experience,  but 
equino- valgus  is  the  commonest  form  of  the  congenital 
deformity,  and  calcaneo-valgus  is  commoner  than  pure 
valgus.  Bouvier  divides  congenital  valgus  into  two  kinds  : 
those  in  which  the  foot  is  simply  flattened  out,  and  those  in 


198 


BODILY    DEFORMITIES. 


which  there  is  a  turning  outwards  of  the  sole.  The  former 
are  not  painful,  but  the  latter  may  be.  The  first  form  is 
really  pes  planus. 

Morbid  Anatomy.— There  have  been  very  few  exami- 
nations of  the  feet  of  infants  affected  with  this  distortion, 
Rignetta  dissected  one,  and  found  that  the  posterior 
tuberosity  of  the  calcis  was  very  short,  thin,  and  thrown 
outwards,  as  was  the  tendo-Achillis.  The  body  of  the 
calcaneus  was  thinner  and  shorter  than  natural,  and  its 
superior  articular  facets  less  marked.     Its   anterior  tube- 


Fig.  87.— Double  congenital  valgus  from  a  girl  aged  two  and  a-half.  In  fore- 
shortening the  heels  appear  drawn  up.  From  a  case  of  mine  at  the  R  oyal  Ortho- 
paedic Hospital. 


rosity  was  directed  inwards  and  participated  in  the  general 
atrophy  of  the  bone.  The  scaphoid  and  cuboid  were 
rotated  inwards  on  an  antero-posterior  axis.  The  fifth 
metatarsal  bone  was  shorter  and  thicker  than  natural,  and 
the  tarsal  ligaments  were  lax,  permitting  greater  motion. 
Adams  observed  that  the  astragalus  was  tilted  down  and 
forwards,  and  that  the  rotation  of  the  scaphoid  left  the 
upper  part  of  the  head  of  the  astragalus  projecting.  He 
also  says  that  the  cuboid  is  slightly  rotated  outwards  and 
not  inwards.  Lacour  examined  the  foot  of  an  adolescent 
born  with  this  deformity,  and  found  that  the  head  of  the 


CONGENITAL    VALGUS.  1 99 

astragalus  was  depressed  on  its  outer  side,  so  that  the  direc- 
tion of  the  astragalo-scaphoid  joint  was  changed.  In  these 
cases  the  malleoli  are  depressed. 

Symptoms— If  the  deformity  have  been  uncorrected, 
when  the  child  begins  to  walk,  and  after  it  has  done  so  for 
a  short  time,  it  will  show  disinclination  to  do  so,  and  will 
cry  if  it  be  put  upon  its  feet  on  account  of  the  pains  pro- 
duced in  the  plantar  region  ;  but  some  cases  growing  into 
childhood  walk  fairly  well.  If  handled,  the  motions  of 
the  foot  are  found  to  be  impeded,  and  the  patients  cannot 
produce  much  voluntary  motion  in  the  tarsal  joints,  and  the 
majority  cannot  raise  themselves  upon  the  feet.  Faradiza- 
tion of  the  peroneus  longus  will  result  in  contraction  in 
some  cases,  but  not  in  others. 

The  pain  experienced  in  this,  and  especially  in  the 
neglected  forms  of  the  malady,  may  be  due  to  paresis  of 
the  peroneus  longus,  or  to  relaxation  of  the  ligaments,  or 
to  altered  direction  of  the  bones  causing  abnormal  pressure 
in  the  joints,  and  on  the  skin  of  the  inner  side  of  the  foot, 
which  gives  rise  to  reflex  cramps. 

In  bad  cases  the  foot  is  curved  up  and  back  at  the 
transverse  tarsal  joint,  the  plantar  ligaments  are  much 
stretched  and  the  dorsal  contracted,  the  calcaneo-scaphoid 
being  often  much  relaxed.  The  retracted  muscles  are  the 
extensor  longus  digitorum,  the  tendo-Achillis,  and  the 
peronei,  the  longus  being  excepted  in  some  forms.  The 
extensor  proprius  pollicis,  digitorum,  and  minimi  digiti  may 
also  be  contracted. 

Treatment.— Rest,  if  it  can  be  obtained,  should  be 
strictly  enjoined,  and  if  the  peroneus  longus  be  weakened 
electricity  must  be  had  recourse  to.  Frictions  and  massage 
of  the  peroneal  region  are  also  serviceable,  and  electricity 
and  subcutaneous  injection  of  strychnine  and  of  eserine 
have  been  recommended  in  paralytic  or  paretic  cases,  but 


200  BODILY    DEFORMITIES. 

it  is  needless  to  say  that  in  congenital  cases  this  treatment 
must  not  be  adopted.  In  such  cases,  if  the  deformity  be 
slight,  manipulations  and  bandaging  to  a  splint  on  the  inner 
side  of  the  leg,  so  as  to  turn  the  sole  towards  it,  will  some- 
times, if  persevered  in,  result  in  cure ;  but  in  the  majority 
of  cases  tenotomy  must  be  performed,  and  first  the  peronei 
and  then  the  extensor  longus  digitorum  and  peroneus  tertius 
should  be  divided,  and  when  the  eversion  and  external 
rotation  are  corrected,  the  tendo-Achillis  will  need  division. 
This  is  in  the  ordinary  form,  i.e.,  equino-valgus,  but  if  there 
be  no  equinus,  of  course  there  will  be  no  need  for  teno- 
tomy of  the  tendo-Achillis. 

The  treatment  of  acquired  valgus  varies  with  its  degree 
and  cause.  In  the  milder  forms,  where  there  is  no  great 
tarsalgia  or  contraction  of  tendons,  the  wearing  of  a  pro- 
perly-adjusted sole-plate  during  the  day,  and  massage  of  the 
foot  night  and  morning,  is  of  great  service.  In  some  cases 
forcible  rectification  under  an  anaesthetic,  and  the  imme- 
diate application  of  a  plaister-of-Paris  bandage  is  of  service. 
In  statical  instances,  rest  must  be  enjoined.  In  articular 
cases,  rest,  and  Scott's  dressing,  strapping,  and  bandaging  are 
indicated.  In  infants  and  young  children,  Mr.  Churchill's 
plaister-of-Paris  bandage  is  serviceable,  and  is  described  in 
the  Medical  Times  for  July  19,  1884.  In  rachitic  valgus  the 
arch  and  instep  of  the  foot  must  be  supported ;  any  defor- 
mities in  the  limbs  throwing  the  line  of  gravity  inwards 
must  be  corrected,  and  any  secondarily  retracted  tendons 
tenotomized.  In  the  paralytic  forms,  as  a  rule,  no  tendons, 
except  the  tendo-Achillis,  need  division,  and  the  same  care 
in  subsequently  stretching  this  tendon  must  be  observed  as 
in  cases  of  paralytic  varus.  It  has  already  been  mentioned 
that  genu  valgum  may  be  the  result  of  talipes  valgus  and 
vice  versa.     Relapse  is  rare  in  properly  treated  cases. 

In  more  aggravated  cases  the  peronei  and  extensor  longus 


CONGENITAL    VALGUS. 


20I 


digitorum  are,  or  become,  prominent  on  attempting  manually 
to  correct  the  deformity,  and  pain  is  produced.  These 
tendons  must  be  divided,  and  subsequently  a  valgus  boot 
and  support,  or  a  Nyrop's  boot,  must  be  worn  for  a  time. 
The  boot  recently  described  by  Mr. 
Walsham  in  the  Lancet  is  Nyrop's 
boot,  as  the  adjoining  figure  will 
show ;  but,  doubtless,  it  was  un- 
known to  him.  I  use  a  boot  the 
sock  or  inner  sole  of  which  is  hol- 
lowed out  on  the  outer  side,  but  the 
inner  side  of  it,  and  of  the  external 
sole,  is  thick,  and  the  latter  is 
bevelled  off  to  the  outer  side  of  the 
foot  A  valgus  boot  and  support 
with  a  strong  T-strap  is  ver>7  useful 
without,  or  after  operation,  if  this  be 
necessary.  Frictions,  massage,  and 
moulding  of  the  foot  are  also  needed 
two  or  three  times  daily. 

Tenotomy— To  divide  the  peronei  the  tenotome  must 
be  passed  between  these  muscles  and  the  edge  of  the 
fibula ;  in  adults,  about  an  inch  and  a  half  above  the  ex- 
ternal malleolus ;  in  infants,  about  half  an  inch  above  it, 
and  the  division  made  towards  the  skin.  To  divide  the 
extensor  longus  and  peroneus  tertius,  the  tenotome  must 
be  inserted  at  the  inner  border  of  the  extensor,  being  care- 
ful not  to  wound  the  anterior  tibial  artery  and  nerve. 
Should  it,  in  any  case,  be  necessary  to  divide  the  tibialis 
anticus  and  extensor  pollicis,  the  same  puncture  will  suffice 
if  the  knife  be  turned  inwards  between  the  anterior  tibial 
vessels  and  the  skin.  x\fter  three  or  four  days  the  foot 
must  be  gradually  put  into  a  correct  position,  and,  unless 
the  case  be  a  severe  one,  a  Scarpa  will  not  be  necessary ; 


Fig.  88.— Nyrop's  valgus  boot. 


202  BODILY    DEFORMITIES. 

but,  if  so,  the  universal  Scarpa,  already  described,  will  be 
found  a  serviceable  instrument.  The  patient  may  then 
wear  a  boot  and  support  with  outside  iron,  the  boot  having 
a  leather  "["-strap.  Inside  the  boot  there  will  be  a  steel 
valgus  sole-plate,  or  wedge-shaped  pads  covered  with  wash- 
leather.  In  some  cases,  where  pressure  cannot  be  borne 
on  the  sole  of  the  foot,  if  the  heel  of  the  boot  be  bevelled 
and  carried  forward  on  the  inner  side,  the  purpose  may 
often  be  answered.  It  is  not  often  that  an  instrument 
passing  up  to  the  pelvis  is  necessary  in  these  cases,  but  the 
patient,  or  the  parents,  should  be  informed  that  massage 
and  manipulations  of  the  foot  in  the  right  direction  are 
necessary  for  some  time. 

In  the  worst  cases,  where  the  foot  is  rigid  and  the  sole 
convex,  Dr.  Alexander  Ogston,  of  Aberdeen,  has  carried 
out  an  operation,  the  results  of  which  Mr.  W.  Adams  spoke 
well  of  at  a  recent  meeting  of  the  Medical  Society ;  but  the 
report  of  the  meeting  does  not  say  if  he  saw  any  of  the 
cases  before  operation,  so  as  to  be  able  to  express  an 
opinion  as  to  its  necessity.  Mr.  Ogston's  paper  is  in  the 
Lancet  for  January  26,  1884.  Mr.  Golding  Bird  has  per- 
formed a  somewhat  similar  operation,  and  has  published 
a  paper  on  the  subject  in  the  Guy's  Hospital  Reports  for 
1883. 

Ogston's  Operation. — An  incision  an  inch  and  a 
quarter  long  is  made  along  the  inner  border  of  the  foot,  its 
middle  corresponding  to  the  astragalo-scaphoid  joint,  which 
is,  in  these  cases,  about  half  an  inch  nearer  the  toes  than 
in  a  normal  foot.  In  severe  cases  the  incision  may  be 
curved.  All  structures  down  to  the  bone  are  divided  by 
this  first  cut.  The  inner  part  of  the  head  of  the  astragalus 
is  generally  visible  through  the  incised  capsular  ligament, 
and  the  wound  being  held  apart  by  aneurism  needles,  free 
access  to  the  joint  is  obtained  by  separating  the  attach- 


CONGENITAL   VALGUS.  203 

merits  of  the  ligaments  for  half  an  inch  anteriorly  and 
posteriorly.  The  ligament  is  then  seized  with  forceps  and 
detached  from  its  connections  to  the  scaphoid,  but  its 
attachments  to  the  periosteum  must  be  preserved  by  cut- 
ting with  the  knife  on  the  flat,  the  edge  being  towards  the 
toes.  A  stout  chisel,  half  an  inch  broad,  and  bevelled  on 
one  side,  is  applied  to  the  head  of  the  astragalus  with  the 
bevelled  side  away  from  it,  and  the  cartilage,  plus  a  thin 
layer  of  subcartilaginous  cancellous  bone,  removed.  The 
chisel  is  then  used  to  the  scaphoid,  the  bevelled  side 
towards  it,  as  the  surface  to  be  denuded  is  concave,  and  by 
repeated  shavings,  the  denudation  proceeds  to  the  required 
extent.  In  old  or  severe  cases,  the  bony  projecting  growth 
on  the  lower  surface  of  the  astragaloid  facet  must  be  re- 
moved. The  next  step  is  to  restore  the  foot  to  its  corrected 
position,  and  while  an  assistant  maintains  this,  to  apply  a 
drill  to  the  upper  and  inner  side  of  the  scaphoid  and 
direct  it  to  the  centre  of  the  caput  tali,  and  a  hole  an  inch 
and  a  quarter  long  is  made  through  both  bones.  An  ivory 
peg  is  then  driven  home  and  the  projecting  part  removed 
by  bone  forceps  on  a  level  with  the  scaphoid.  A  second 
perforation,  parallel  with  the  first  and  half  an  inch  from  it, 
is  then  made  through  the  two  bones  and  another  peg  fixed 
in.  The  wound  is  then  closed  and  the  foot  put  up  in  Paris 
plaister.  Ogston  uses  strict  antisepticism.  The  patients 
suffer  sharp  pain  for  twenty-four  hours.  They  must  be 
kept  in  bed  for  two  or  three  months  and  may  then  walk. 
He  has  operated  seventeen  times  on  ten  patients,  i.e.,  seven 
double,  three  single.  In  one  case  he  pegged  the  joint  be- 
tween the  scaphoid  and  internal  cuneiform.  Great  benefit, 
he  says,  resulted  from  the  operation  and  bony  anchylosis 
and  a  painless  arch  were  obtained. 

It  must  always  be  remembered  that  all  bone  operations 


204  BODILY    DEFORMITIES. 

in  any  form  of  talipes  are  to  be  avoided,  except  in  extreme 
cases  and  after  other  methods  have  failed,  and  in  valgus 
the  very  large  majority  of  cases  are  perfectly  amenable  to 
tenotomy,  proper  instruments,  massage,  and  a  correctly 
constructed  boot  and  support.  Moreover,  six  weeks  is  the 
average  time  needed  to  restore  these  patients  to  comfort  by 
ordinary  orthopaedic  means,  whereas  several  months'  care 
is  required  after  any  operation  on  the  tarsal  bones  and 
joints. 


205 


CHAPTER   XIII. 


PES    EQUINUS. 


Synonyms.— German,  Pferdefuss,  Spitzfuss  ;  French,  Pied 

hot  equin. 

Definition— In  this  deformity  the  foot  is  extended,  the 
heel  being  drawn  up,  and  the  patient  walks  on   the  ball  of 
the  toes.     In  severer  forms  the  toes  may  be  flexed,  and  the 
patient  bears  the  weight  on  the  phalanges  and  heads  of  the 
metatarsal  bones,  and,  in  the  worst  cases,  he  walks  on  the 
head  of  the  astragalus,  over  which  a  bursa  is  developed ; 
the  toes  curl  up  and  back,  and  the  sole  of  the  foot  is  much 
contracted  and  creased.     The  foot  is  also  broadened,  and 
this,  added  to  the  heel  being  drawn  up,  gives  a  sort  of  re- 
semblance  to    a   horse's   hoof,    hence   the   name    of  the 
deformity. 

Varieties.— It  may  be  congenital  or  acquired,  the  former 
being  rare,  but  the  latter  common,  for  the  paralytic  defor- 
mity is  often  met  with,  though  it  is  not  so  common,  in  my 
experience,  as  acquired  valgus. 

CONGENITAL    EQUINUS. 

Pure  equinus  of  this  form  is  rare.  Its  cause,  like  those 
in  the  other  forms  of  club-foot  not  due  to  defective  de- 
velopment, is  said  to  be  due  to  inter-uterine  abnormal 
pressure,  or  mal-position  in  utero.     It  may  also  be  due  to 


2o6 


BODILY    DEFORMITIES. 


irritative  contraction  of  the  gastrocnemius  and  soleus. 
As  the  congenital  forms  of  club-foot  are 
rarely,  now-a-days,  allowed  to  progress,  and 
as  it  is  readily  diagnosed,  I  may  pass  on 
to  the  neglected  forms,  whether  congenital  or 
acquired.  The  figures  on  the  next  page,  of  a 
rare  case  of  this  deformity,  are  drawn  from  a 
young  patient  of  mine  at  the  Royal  Ortho- 
paedic Hospital.  There  was  limited  motion 
at  the  knees,  and  also  at  the  elbows  and 
wrists,  and  the  labia  majora  were  represented 
by  depressions  instead  of  prominences.  The 
Congenital  profile  view  necessitated  outward  rotation  of 
the  femora. 


Fig 


equinus. 


ACQUIRED    EQUINUS. 

Definition. — This  is  a  deformity  in  which  the  heel  is 
drawn  up  towards  the  calf,  and  the  subject  walks  on  the 
balls  of  the  toes. 

Causes. — These  are  generally  nerve  lesions,  traumatism, 
or  joint  diseases.  The  first  may  be  divided  into  paralytic 
and  spasmodic  or  spastic ;  the  next  into  wounds,  burns, 
and  cicatrices,  and  the  last  to  the  position  assumed  being 
in  the  direction  of  least  pressure  in  consequence  of  the 
pain  of  articular  mischief.  Further  remarks  on  this  subject 
will  be  found  in  the  paragraph  on  diagnosis. 

Degrees  and  Varieties— There  appear  to  be  three 
well-marked  stages.  In  the  first  the  heel  is  drawn  up  and 
the  toes  extended,  but  the  foot  may  be  forced  to  nearly,  or 
quite,  a  right  angle  with  the  leg.  In  the  second  form  there 
is  more  retraction  of  the  calf  muscles,  and  the  axis  of  the 
foot  and  leg  are  in  one  line.  In  such  cases  the  patient 
often  walks  on  the  phalanges  and  heads  of  the  metatarsals. 


ACQUIRED    EQUINUS. 


207 


In  the  third y  the  anterior  portion  of  the  foot  is  bent  back- 
wards, and  the  patient  walks  on  the  tarsal  bones.  To  that 
form  in  which  the  toes  are  extended  in  their  whole  length, 
or  only  at  the  metatarso-phalangeal  joint,  the  term  plantar 
equinus  has  been  given ;  but  when  the  toes  are  flexed  and 


Figs.  90  and  91. — Congenital  neglected  equinus  from  a  girl  aged   five,  seen  from 
the  front  and  in  profile. 


the  patient  walks  on  their  dorsal  surface,  it  is  called  dorsal 
equinus.  In  the  former  there  is  no  marked  change  in  the 
sole,  but  in  the  latter  it  becomes  hollow  and  creased,  and 
this  condition  may  be  termed  equino-cavus.  This  form  of 
the  deformity  may,  when  due  to  nerve  lesion,  be  spastic 


2o8  BODILY    DEFORMITIES. 

or  paralytic.  The  former  is  due  to  irritation  in  the  nerve 
centres  or  nerves,  and  is  an  early  phenomenon,  but  most 
cases  come  under  observation  in  the  paralyzed  stage.  The 
symptomatic  form  is  adverted  to  further  on. 

Pathological  Anatomy.— This  consists  rather  in  a 
change  of  position  than  of  form,  except  in  late  stages. 

Bones. — The  astragalus  is  only  in  contact  with  the  tibia 
and  fibula  by  the  posterior  part  of  its  articular  surface  being 
displaced  downwards,  and  forming  a  projection  on  the 
dorsum  of  the  foot,  which  is  due  to  its  sub-luxation  from 
the  scaphoid,  which  is  pressed  downward  and  brought  near 
to  the  os  calcis,  and  sometimes  the  two  articulate.     The 


Fig.  92. — Ordinary  form  of  equinus,       Fig.  93. — More  aggravated  form 
the  toes  extended.  with  the  toes  flexed. 

posterior  part  of  the  os  calcis  is  raised,  and,  in  certain  cases, 
may  be  in  contact  with  the  tibia  and  fibula.  In  some 
instances  the  calcis  simply  follows  the  astragalus,  but  as  a 
rule  it  is  not  so.  If  the  calcaneus  is,  or  appears  to  be, 
depressed  at  its  anterior  part,  so  that  the  astragalus  and  it 
appear  to  approach  each  other  in  front  and  gape  behind, 
the  result  is  that  the  calcis  is  in  a  less  extended  position 
than  the  astragalus.  In  milder  forms,  the  lowering  of  the 
anterior  part  of  the  foot  is  usually  dependent  on  the  con- 
traction of  the  tendo-Achillis,  but  in  the  severer  stages  the 
plantar  arch  becomes  contracted,  and  the  distortion  may 


ACQUIRED    EQUINUS.  209 

be  dependent  on  this,  and  on  the  contraction  of  the  sole 
muscles,  producing  a  flexion  of  the  transverse  tarsal  joint, 
which  is  a  secondary  result  of  the  heel  elevation.  The 
anterior  part  of  the  calcis  is,  in  these  severe  cases,  sub- 
luxated  from  the  cuboid,  being  raised  above  it.  The 
articular  cartilages  gradually  disappear  from  those  surfaces 
not  in  contact  with  neighbouring  bones.  In  severe  cases 
the  base  of  the  fifth  metatarsal  may  be  nearly  in  contact 
with  the  calcis  ;  and  Chance  has  described  a  case  in  which 
a  facet  had  formed  on  the  calcis  behind  the  astragalus  for 
articulation  with  the  tibia.  In  this  case  the  articulating 
surfaces  of  the  astragalus  were  somewhat  altered.  In 
severe  cases  of  long  standing  the  proximal  phalanges  form 
articular  facets  upon  the  upper  surfaces  of  the  metatarsal 
bones,  in  consequence  of  the  anterior  surface  of  the  foot 
being  used  for  the  purposes  of  progression.  In  old  cases, 
the  bones  have  been  found  light  and  porous,  but  in  cases 
of  over  fifty  years'  standing,  the  disease  is  perfectly  amenable 
to  correct  orthopaedic  treatment. 

Ligaments. — These  are  contracted  in  the  sole  and 
stretched  on  the  dorsum.  The  plantar  fascia  is  always 
firmly  contracted  in  severe  cases.  The  astragalo-scaphoid 
ligament  may  be  much  stretched  in  old  cases,  as  are  also 
the  interosseus  and  calcaneo-astragaloid. 

Muscles.  —  The  gastrocnemius,  soleus,  plantaris,  and 
flexor  brevis  digitorum  are  retracted  in  the  severe  cases, 
and,  sometimes,  in  the  worst  cases,  the  deep  muscles  as 
well,  especially  the  flexor  longus  digitorum.  The  peroneus 
iongus  is  often  shortened,  and  it  is  to  this  retraction  that 
some  attribute  the  cavus  which  is  present  in  those  cases 
where  the  toes  are  extended.  The  extensors  may  also 
become  retracted  through  the  altered  position  of  the  toes, 
for  instance,  the  extensor  communis  and  extensor  pollicis, 
and  in  these  cases  the  toes  are  extended  ;  but  if  the  flexors 

p 


2IO  BODILY    DEFORMITIES. 

be  retracted  the  toes  are  flexed.  The  tendency,  of  course, 
is  for  the  toe  flexors  to  become  first  shortened,  but  if  the 
patient  bear  his  weight  at  first  on  the  plantar  aspect  of  the 
toes,  these  are  constantly  lengthened  and  the  extensors  may 
thus  become  shortened.  The  flexor  brevis  digitorum  is 
often  retracted,  and  with  the  abductor  pollicis  and  minimi 
digiti  help  to  produce  the  concavity  of  the  sole,  which 
commences,  in  bad  cases,  at  the  free  extremities  of  the  toes, 
which  are  sometimes  bent  up,  and  extends  to  the  heel. 
This  cavus  differs  from  ordinary  pes  cavus,  in  which  the 
concavity  only  begins  at  the  head  of  the  metatarsal  bones. 
Pancoast  says  that  the  soleus  is  wholly  or  chiefly  retracted, 
but  experience,  as  well  as  experiment,  show  this  view  to  be 
wrong ;  for  if  the  gastrocnemius  and  plantaris  did  not  influ- 
ence the  amount  of  the  deformity,  why  should  there  be 
variations  in  it  when  the  limb  is  flexed  or  extended  ?  In- 
stead of  the  soleus  only  being  affected,  one  would  be 
inclined  to  think  that  beyond  the  muscles  just  named  the 
peroneus  longus  is  also  affected  in  pure  equinus.  We 
know  that  the  muscles  acting  through  the  tendo-Achillis 
produce  slight  abduction  as  well  as  extension,  and  if  exten- 
sion be  in  a  right  line,  the  action  of  the  peroneus  longus  is 
necessary  to  produce  the  deformity,  and  probably  also,  in 
part,  that  of  the  brevis.  The  tendons  are  rarely  much,  if 
at  all,  displaced  in  this  affection  ;  in  fact,  equino-varus  seems 
to  be  the  only  distortion,  which  in  its  severe  forms,  produces 
any  great  displacement  of  tendons. 

Symptoms— The  patient  either  drags  the  leg  along, 
or  swings  it  with  a  circular  motion,  or  brings  it  down  with 
a  jerk  from  the  toe  to  heel ;  the  calf  and  the  whole  leg  are 
wasted,  and  the  former  is  raised.  In  severe  cases  there  are 
transverse  creases  at  the  heel  above  the  os  calcis.  The 
reason  of  these  peculiarities  of  gait  is  that,  the  foot  being 
extended,  the  limb  is  longer  on  that  side.     Sometimes  the 


ACQUIRED    EQUINUS. 


2TI 


patient  overcomes  it  by  flexing  the  knee.  Secondary 
distortions,  such  as  tilting  of  the  pelvis  and  lateral  curvature, 
only  occur,  as  a  rule,  in  late  stages,  when  the  disease  has 
lasted  a  long  time.  Muscular  retraction  in  these  cases,  as 
in  most  others,  produces  a  greater  amount  of  distortion 
than  do  joint  deformities  or  ligamentous  retractions,  and 
it  is  very  rare,  if  the  extensors  be  relaxed,  that  the  foot 
cannot  be  slightly  more  flexed  than  if  the  muscles  were 
acting.  If,  in  the  irritative  or  spastic  cases,  the  patient 
have  walked  for  some  time,  the  anterior  part  of  the  foot 
becomes  widened  and  the  toes  bent.     The  head  of  the 


Fig.  94. — More  severe  form  of 
equinus,  the  weight  being  borne  on  the 
heads  of  the  metatarsals. 


Fig.  95. — Extreme  stage, 
the  patient  walking  on  the 
dorsum. 


astragalus  is  prominent  on  the  dorsum  of  the  foot,  the  leg 
may  become  shorter  and  the  foot  smaller  through  im- 
proper growth.  The  plantar  fascia  and  short  muscles  on 
the  inner  side  of  the  foot  may  become  contracted  and  cause 
partial  inversion  and  shortening  of  this  side  of  the  foot. 
The  ligaments  of  the  sole  are  shortened,  and  the  dorsal 
ones  become  stretched.  Corns  or  bursas  may  form  in  the 
sole  at  the  metatarso-phalangeal  joint,  and  if  they  become 
inflamed  may  give  rise  to  much  trouble.  I  have  known  these 
in  spastic,  and  especially  in  paralytic  equinus,  to  cause  joint 
and  bone   mischief,   and  to  simulate,  or  in  fact  become, 

p  2 


212  BODILY    DEFORMITIES. 

perforating  ulcers  of  the  foot.  It  must  be  borne  in  mind 
that  in  all  paralytic  forms  pressure  is  very  badly  borne  ; 
and  sores,  especially  in  cold  weather,  are  apt  to  form, 
and  are  difficult  to  heal.  In  these  cases  the  coldness  and 
redness,  or  purplish  hue  of  the  limb,  and  the  great  wasting 
of  the  muscles  is  obvious.  The  swing  of  the  affected  limb 
is  characteristic,  and  the  up  and  down  gait  of  the  patient 
cannot  well  be  mistaken.  The  aspect  of  the  foot  will  vary 
according  to  the  muscles  affected.  If  the  anterior  muscles 
are  normal,  the  toes  will  be  extended  ;  but  if  these  and  the 
flexor  longus  digitorum  be  contracted,  the  distal  phalanges 
will  become  flexed  and  clawed.  If  the  anterior  muscles 
be  paralyzed,  and  the  foot  little  used  for  progression  or 
support,  the  toes  become  entirely  flexed ;  but  if  much  used, 
dorsal  progression  will  be  the  result. 

Diagnosis.— Not  the  deformity,  but  its  cause,  may  give 
some  trouble  to  ascertain,  and  the  questions  to  decide  will 
be  whether  the  case  be  spastic,  or  an  old  congenital  one, 
or  due  to  traumatism  or  articular  mischief.  Paralytic 
cases  are  usually  easily  recognized.  In  slight  or  moderate 
cases,  if  flexion  be  permitted  at  the  knee,  the  gastrocnemius 
and  soleus  becoming  relaxed,  will  allow  more  flexion  at  the 
ankle,  so  that  the  equinus  will  disappear,  and  a  severe  one 
will  often  considerably  diminish. 

Paralytic  equinus  is  caused  by  a  paralysis  of  the  exten- 
sors, and  is  oftenest  due  to  infantile  paralysis,  but  is  not 
very  uncommon  in  hemi-  or  paraplegia  of  adults. 

In  consequence  of  loss  of  nerve  power,  the  tendons  and 
ligaments  supporting  the  ankle  and  knee  joints  yield,  so 
that  the  foot  and  the  knee  may  become  valgoid  and  the 
bones  altered  in  shape  and  atrophied.  In  slight  cases, 
going  up  stairs  and  even  dancing  may  be  comparatively 
easy,  but  long  standing,  walking,  and  going  down  stairs 
are  difficult  and  often  painful.     The  reason  why  the  heel 


ACQUIRED    EQUINUS.  2T3 

is  more  drawn  up  in  walking  than  when  at  rest  is  because 
then  the  calf  muscles  are  in  action  and  are  unopposed  by 
the  extensors.  If  both  feet  be  affected,  flexion  of  the 
trunk  at  the  hips  will  occur  in  order  to  permit  the  heels 
to  touch  the  ground,  and,  after  a  time,  progression  without 
the  aid  of  crutches — with  or  without  leg  supports — is 
impossible.  In  acute  cases  many  of  these  symptoms  come 
on  rapidly,  but  in  sub-acute  and  chronic  forms  two  to 
five  years  may  elapse  before  the  child  is  able  to  walk 
at  all. 

Hueter  attributed  the  production  of  paralytic  equinus 
to  the  position  of  the  limbs  in  bed.  The  patient  lies  on 
the  back,  and  the  weight  of  the  bedclothes  assists  the 
unopposed  flexors  by  pressing  on  the  dorsal  surface  of  the 
foot  and  keeping  it  in  an  extended  position. 

Most  of  the  cases  of  paralytic  equinus  are  due  to  the 
causes  already  enumerated,  and  which  speak  for  themselves. 
Here  I  need  only  speak  of  the  variety  due  to  spastic  con- 
traction and  retraction  of  the  flexor  muscles,  and  especially 
of  those  of  the  calf,  but  it  must  not  be  forgotten  that  this 
may  be  a  secondary  result  of  the  other  causes.  For 
instance,  it  may  result  from  anchylosis  after  ankle 
disease ;  and  this  may  cause  a  reflex  contraction,  or 
a  retraction  which  remains  after  the  primary  disease  has 
been  cured.  AVounds  of  muscles  causing  inflammation  of 
them,  and  the  production  of  cicatricial  tissue,  may  also 
produce  this  deformity ;  and  I  have  seen  several  instances 
of  this  after  severe  injuries  to  the  leg  at  the  London 
Hospital.  In  fractures  of  the  leg  in  which  the  foot  has 
not  been  kept  at  the  proper  angle,  the  same  deformity  may 
result.  Injuries  and  diseases  of  the  central  nervous  system, 
or  of  the  nerves  of  the  lower  limb  may,  of  course,  give 
rise  to  the  deformity.  It  must  be  recollected  that  it  is  the 
muscles  in  front  of  the  leg  which  are  paralyzed  in  these 


214  BODILY    DEFORMITIES. 

nervous  cases,  so  that  if,  in  tenotomy  of  the  biceps,  the 
external  popliteal  nerve  be  divided,  an  equinus  would  result 
if  the  nerve  did  not  unite. 

Symptomatic  Equinus. — In  people  with  one  leg  shorter 
than  the  other  from  any  cause,  the  toes  are  often  pointed 
so  as  to  equalize  the  length  of  the  legs.  This  is  an 
accommodative  effort,  and  may  be  termed  compensatory 
equinus. 

Prognosis.— In  the  rare  congenital  cases  this  is  favour- 
able, and  appropriate  treatment  will  soon  set  right  the 
deformity,  but  in  the  acquired  forms  it  will  depend  upon 
the  cause  producing  the  deformity  and  the  amount  of 
damage  to  the  parts,  whether  this  be  primary  or  secondary. 
In  old  spastic  cases  the  anterior  leg  muscles  having  been 
long  extended  and  inactive  will  have  lost  some  of  their 
power,  but  this  may  be  overcome  by  massage,  frictions  and 
use,  unless  degeneration  of  muscular  fibre  have  taken  place. 
In  paralytic  cases  the  deformity  can  readily  be  corrected, 
but  one  must  be  careful  not  to  produce  the  opposite  condi- 
tion by  too  rapid  correction  of  the  displaced  foot. 

Treatment.— In  congenital  equinus  treatment  should  be 
begun  early,  for  in  old  cases  of  this  form  the  distortion  is 
less  amenable  to  treatment  than  are  those  of  neglected  varus 
or  valgus.  The  treatment,  subsequent  to  tenotomy,  if 
this  be  necessary,  is  conducted  on  the  same  principles  as 
for  other  forms  of  club-foot. 

'  In  acquired  cases  the  treatment  must  vary  with  the  cause 
Mild  cases  may  be  amenable  to  manipulations,  and  the  use 
of  appropriate  apparatus,  but  the  severer  forms,  whether 
paralytic  or  not,  will  most  often  need  tenotomy. 

Cases  due  to  joint  mischief,  wounds,  cicatrices,  &c,  must 
be  dealt  with  on  general  surgical  principles.  I  need  only 
here  speak  of  the  Orthopaedic  methods  in  cases  of  spastic 
and  paralytic  equinus.     In  the  former  the  tendo-Achillis 


ACQUIRED    EQUINUS.  215 

must  be  divided,  but  if  the  plantar  fascia  be  contracted,  or 
any  of  the  short  muscles  of  the  foot,  these  should  be 
divided  first  and  the  sole  concavity  corrected  before  the 
tendo-Achillis  is  divided,  because  this  fixes  the  os  calcis  and 
forms  a  steady  point  from  which  to  stretch  out  the  plantar 
fascia,  &c. 

In  paralytic  cases  in  an  early  stage,  faradization,  frictions, 
and  a  suitable  apparatus  may  do  a  good  deal,  but  in  the 
later  stages  tenotony  of  the  tendo-Achillis  will  be  necessary, 
and  before  this  operation  is  done  in  any  variety  of  the 
deformity,  the  boot  and  support  that  will  be  necessary 
should  be  measured  and  ready  for  use  when  required. 
If  the  toes  be  secondarily  contracted,  these  may  be  cor- 
rected by  being  strapped  for  some  time  in  a  proper  position, 
but  if  they  resist  this  the  tendons  producing  the  contrac- 
tion must  be  subcutaneously  divided.  From  four  to  six  days 
may  elapse  before  commencing  the  stretching  in  spastic 
cases,  and  a  little  longer  interval  may  be  allowed  in  paralytic 
forms.  When  the  deformity  is  nearly  corrected  the  use  of 
the  universal  Scarpa,  mentioned  in  the  chapter  on  equino- 
varus,  is  very  serviceable  until  the  patient  is  allowed  to 
walk,  when  an  apparatus,  as  shown  in  one  of  the  adjoining 
figures,  must  be  used.  The  larger  one  consists  of  a  pelvic 
band  and  an  outside  iron  attached  to  a  boot.  There  are 
joints  at  the  hip,  knee,  and  ankle,  but  opposite  the  knee 
there  is  a  stop-joint  which  supports  the  knee,  which  is  gene- 
rally weak  in  these  cases,  and  in  severe  forms  is  hyperex- 
tended,  so  as  to  present  a  convexity  in  the  popliteal  space, 
instead  of  in  front.  The  joint  at  the  knee  permits  fixation 
for  walking,  but  can  be  shifted  to  allow  flexion  in 
sitting.  This  instrument,  passing  from  the  pelvis  to  the 
foot,  prevents  that  rotation  at  the  knee  which  is  due  to 
laxity  of  its  supporting  structures,  and  can  also  be  made  to 
prevent  the  eversion  of  the    toes  and  valgoid  condition 


2l6 


BODILY    DEFORMITIES. 


which  is  apt  to  occur  in  cases  that  are  without  treatment. 
These  latter  conditions  may  be  due  to  paralysis  of  the 
tibialis  anticus,  or  to  contraction  of  the  peronei.  I  should 
mention  that  there  are  some  cases  of  equinus  and  of  equino- 
varus,  in  which,  after  division  of  the  tendo-Achillis,  the 
joint  appears  to  lock,  i.e.,  not  to  become  fully  corrected, 
and,  in  several  instances,  I  have  had  to  divide  the  peronei 
before  the  deformity  was  cured.     Sometimes  the  flexor  and 


Fig.  96. — Boot  and  sup- 
port with  elastic  traction  for 
equinus. 


Fig.  97. — Pelvic  band   and 
support  for  paralytic  equinus. 


extensor  longus  poilicis,  one  or  both,  need  division,  and 
the  latter  especially,  if  the  great  toe  be  much  flexed.  With 
the  treatment  above  given  an  ordinary  case  of  spastic 
equinus  can  be  cured,  as  a  rule,  within  a  fortnight ;  but 
severer  cases,  as  well  as  the  paralytic  forms,  require  more 
prolonged  care. 

Division  of  the  Plantar  Fascia.— The  patient  should 
lie  on  the  face,  so  that  the  foot-sole  is  uppermost.     An 


ACQUIRED    EQUINUS.  217 

assistant  grasps  the  heel  with  one  hand,  and  the  balls  of  the 
toes  with  the  other,  and  stretches  the  foot  to  render  the 
fascia  tense.  The  operator  having  made  out  its  inner 
border,  the  assistant  should  slightly  relax  the  sole  when  the 
surgeon  introduces  the  tenotome  on  the  flat  beneath  the 
fascia  as  far  as  necessary,  then  turns  the  cutting  edge 
towards  it,  and  with  a  sawing  motion  divides  it  entirely,  or 
in  part,  as  thought  advisable.  Directly  the  tenotome  is 
introduced,  the  assistant  again  stretches  the  foot,  before  the 
operator  begins  to  cut.  The  fascia  may  be  divided  near 
its  origin,  at  its  middle,  or  nearer  the  toes.  The  great 
point  is  not  to  pass  the  knife  too  deeply  so  as  to  wound  the 
plantar  vessels.  The  operation  completed,  a  dossil  of  lint, 
fixed  with  strapping  and  bandage,  should  be  applied  over 
the  puncture,  and  the  foot  put  on  a  flexible  splint  in  the 
deformed  position  until  the  third  day,  when  stretching  of 
the  fascia  should  begin. 

Excision  of  the  Astragalus  for  equinus  was  first  per- 
formed by  Mr.  Lund,  of  Manchester,  upon  an  infant,  in 
1877,  as  stated  in  the  chapter  on  Varus.  The  head  of  the 
astragalus  was  exposed,  the  interosseus  calcaneo-astragaloid 
ligament  was  hooked  out  and  cut,  the  hook  being  sharp  on 
its  concave  surface,  then  the  astragalus  was  removed.  This 
operation  is  only  justifiable  in  cases  occurring  in  adults  and 
of  long  standing,  after  the  ordinary  methods  have  had  a 
fair  trial  and  failed. 


2l8  BODILY    DEFORMITIES. 


CHAPTER   XIV. 

TALIPES    CALCANEUS. 

Synonyms. — German,  Hackenfuss  ;  French,  Pied  bot  talus. 

Definition. — This  deformity  consists  in  the  foot  being 
flexed  upon  the  leg,  so  that  its  dorsum  approximates  the 
front  of  the  leg  •  the  heel  is  depressed  and  the  sole  raised. 

Varieties. — It  may  be  congenital  or  acquired ;  the  former 
is  very  rare,  the  rarest  of  all  the  congenital  forms  of  club- 
foot, and  the  acquired  form  is  also  uncommon,  except  as  a 
result  of  paralysis.  The  congenital  form  is  almost  always 
associated  with  valgus,  so  that  pure  calcaneus  is  extremely 
rare. 

CONGENITAL    CALCANEUS. 

Degrees.— There  may  be  slight  or  severe  forms  of  this 
deformity,  and,  accordingly,  three  degrees  of  it  have  been 
made  :  i.  When  the  foot  is  at  a  right  angle  to  the  leg,  and 
extension  cannot  be  carried  beyond  that  point;  2.  The 
foot  is  at  an  acute  angle  to  the  leg ;  3.  The  dorsal  aspect 
of  the  foot  nearly,  or  quite,  touches  the  anterior  surface  of 
the  leg. 

Symptoms.— If  the  infant  be  supported  in  a  standing 
position,  it  will  be  found  that  the  heel,  and  in  severe  cases 
its  posterior  part  only,  comes  in  contact  with  the  ground, 
the  toes  being  raised  and  the  sole  pointing  forwards.  The 
former  are  often  flexed,  especially  the  four  outer  toes.     On 


CONGENITAL    CALCANEUS. 


219 


attempting  to  extend  the  foot  the  tendons  of  the  tibialis 
anticus,  extensor  longus  digitorum,  and  pollicis  may  be  felt 
to  be  very  tense.  The  tendo-Achillis  is  closely  applied  to 
the  back  of  the  tibia,  and  the  projection  of  the  heel  is 
absent.  Though  the  displacement  occurs  at  the  tibio- 
astragaloid  joint,  there  may  be 
a  movement  of  the  anterior 
part  of  the  foot  on  the  pos- 
terior, at  the  mid-tarsal  joint, 
the  effect  of  which  is  to 
flatten  the  dorsal  convexity 
of  the  instep,  and  to  diminish 
the  plantar  concavity.  There 
are  skin-folds  and  creases  on 
the  dorsum  near,  and  at  the 
ankle. 

Pathological    Anatomy. 
— The  bones   are  not   much 

altered,  but  the  articular  surfaces  are  somewhat  modified, 
The  astragalus  appears  to  be  pushed  backwards,  and  a  part 
of  its  neck  is  in  contact  with  the  tibio-fibular  surfaces, 
whilst  the  anterior  part  of  its  upper  articular  facet  is  behind 
the  tibia  and  uncovered  by  it.  The  os  calcis  follows  the 
astragalus  in  its  posterior  movement.  Lannelongue  found 
the  astragalus  as  if  displaced  towards  the  posterior  part  of 
the  os  calcis.  The  same  writer  found  the  astragalus  some- 
what defective  in  front  though  well  developed  behind. 

At  a  later  stage  inverse  changes  result,  and  a  slight 
displacement  occurs  between  these  bones,  which  leaves 
uncovered  a  part  of  the  postero-inferior  astragaloid  facet, 
and  the  axes  of  these  bones  form  an  angle  open  behind. 


Fig.  98. — Congenital  calcaneus.  The 
patient  fiad  six  toes,  and  the  second, 
third,  fourth,  and  fifth  were  webbed. 


2  20  BODILY    DEFORMITIES. 


ACQUIRED    CALCANEUS. 


Causes.— Of  these  paralysis  is  by  far  the  commonest, 
though  injury  and  disease  may  produce  it.  The  too  rapid 
lengthening  of  the  tendo-Achillis,  after  section  in  paralytic 
cases,  will  also  produce  it.  The  spasmodic  or  spastic  form 
is  rare.  The  paralytic  form  is  due  to  paresis  of  the  sural 
muscles,  and  the  consequent  uncontrolled  action  of  the 
anterior  muscles. 

Symptoms.— I  have  seen  several  well-marked  examples 
of  the  deformity  at  the  Royal  Orthopaedic  Hospital,  in 
various  stages  of  the  malady,  and  have  found  it  most 
frequently  as  a  result  of  infantile  paralysis.  In  these  the 
flexion  of  «the  foot  is  generally  not  extreme,  and  there  is 
often  associated  with  it  a  valgoid  condition  of  the  postero- 
internal part  of  the  foot ;  and  there  is,  almost  always,  the 
condition  known  as  pes  cavus,  i.e.,  the  arch  of  the  foot  is 
shortened,  and  is  higher  and  more  concave.  The  character 
of  this  cavus  varies  with  the  stage  of  the  disease  and  the 
number  of  muscles  affected.  If  only  the  triceps  suralis  be 
paralysed  there  will  be  what  Duchenne  calls  a  direct  cavus. 
In  this  the  tibialis  anticus,  extensor  longus  digitorum,  and 
extensor  proprius  pollicis,  flex  the  foot,  and  the  flexor  longus 
digitorum  and  peroneus  longus,  bend  the  anterior  on  the 
posterior  part  of  the  foot,  and  form  a  direct  calcaneo-valgo- 
cavus.  In  this  deformity  the  plantar  part  of  the  anterior 
portion  of  the  foot  looks  directly  downwards. 

If  the  peroneus  longus  be  also  paralysed  the  flexor 
digitorum  longus  is  not  counteracted  by  it,  and  there  will 
result  a  calcaneo-cavus  with  varus  of  the  anterior  part  of  the 
foot,  i.e.,  with  inversion  of  the  anterior  part  of  the  sole. 
If  the  flexors  be  paralysed  and  the  peroneus  longus  normal, 
a  cavo  valgus  will  result,  i.e.,  a  cavus  with  the  anterior  part 


ACQUIRED    CALCANEUS  221 

of  the  sole  turned  outwards,  but  in  these  forms,  the  chief 
factor  in  increasing  the  plantar  concavity,  is  the  depression 
of  the  os  calcis. 

The  toes  are  raised  towards  the  dorsum  of  the  foot  if  the 
interossei  be  intact,  but  they  are 
flexed  if  these  be  paralysed.  This 
is  a  similar  condition  to  that 
known  in  the  upper  limb  as  clawed 
or  griffin  hand. 

The  patient  swings  the  leg  and 
brings  it  down  upon  the  heel, 
and  sometimes  on  the  posterior 
part  of  it,  and  when  this  touches 

the    ground    the    anterior    part    Of       FlG-  99-~ Paralytic  calcaneus. 

the  foot  hangs,  as  it  were,  on  it, 

unless  the  plantar  fascia  and  plantar  muscles  be  strongly 
retracted  •  the  leg  and  foot  are  much  wasted,  and  if  the 
disease  have  lasted  long,  the  bones  are  considerably  atro- 
phied. The  limb  is  colder  and  of  a  bluish-purple,  and 
chilblains,  and  pressure  sores,  are  apt  to  form  and  are 
difficult  to  heal.  In  cases  combined  with  valgus,  the 
patient  walks  on  the  inner  malleolus,  and  I  have  seen  the 
bursas  which  form  in  this  situation  give  trouble  through 
their  inflaming. 

In  that  rare  affection  spasmodic  calcaneus  the  muscles  on 
the  front  of  the  leg  are  contracted,  and  in  later  stages 
become  retracted,  and  then  must  be  divided  to  reduce  the 
deformity. 

Morbid  Anatomy.— In  addition  to  the  displacement 
described  in  the  congenital  form,  a  diminution  of  the 
antero-posterior  dimensions  of  the  plantar  portions  of  the 
scaphoid  and  cuboid  result.  The  os  calcis  appears  elongated 
and  its  posterior  part  more  conical,  while  it  has  become 
almost  vertical  in  position,  and  the  astragalus  is  obliquely 


222  BODILY    DEFORMITIES. 

placed  to  it.  The  ligaments  on  the  dorsal  surface  and  in 
the  sole  of  the  foot  are  contracted,  and  especially  the  plantar 
fascia,  but  at  the  back  of  the  ankle  they  are  lengthened. 

Mr.  W.  Adams  has  described  the  feet  of  Chinese  women 
in  the  Royal  College  of  Surgeons'  Museum.  These  are 
cases  of  artificial  calcano-cavjis,  but  they  differ  from  the 
natural  form  in  that  the  four  outer  toes  are  flexed,  and 
rotated  towards  the  mid-line  of  the  sole.  They  are  also 
depressed,  being  lower  than  the  displaced  os  calcis.  The 
great  toe  is  the  only  one  which  is  in  extension,  and  this 
gives  the  pointed  form  to  the  foot.  The  instep  is  much 
increased  on  the  dorsum,  and  this  is  due  to  the  almost 
vertical  position  of  the  metatarsal  bones,  and  the  projec- 
tions of  the  anterior  tarsal  bones  articulating  with  them. 

Prognosis.— In  congenital  cases  this  is  favourable,  be- 
cause there  is  rarely  any  increase  of  the  deformity,  and 
suitable  treatment  will  soon  rectify  the  foot.  In  spasmodic 
cases,  tenotomy  with  proper  subsequent  treatment  will  also 
do  much  for  the  defect ;  but  in  paralytic  cases,  entire  removal 
of  the  deformity  is  scarcely  to  be  expected,  and  even  if 
this  were  done,  we  have  no  present  means  of  restoring 
motion,  unless  the  cases  be  seen  early,  which  unfortunately 
they  rarely  are. 

Treatment.— In  infants,  the  deformity  being  spasmodic, 
is  readily  amenable  to  extension  by  splints,  but  if  not,  it  will 
yield  to  tenotomy  and  subsequent  manipulations.  In  these, 
as  in  adult  spasmodic  cases,  the  tibialis  anticus,  extensor 
longus  digitorum,  proprius  pollicis  and  the  peroneus  tertius 
usually  require  division,  when  rectification  soon  occurs, 
and  then  the  use  of  the  universal  Scarpa  for  a  short  time 
will  entirely  correct  the  deformity,  which  is  not  apt  to 
relapse. 

In  acquired  cases,  of  which  the  paralytic  are  by  far  the 
commonest,  tenotomy  of  tendons  is  not  often  necessary, 


ACQUIRED    CALCANEUS.  223 

but  the  plantar  fascia,  and  even  some  of  the  contracted 
superficial  plantar  muscles,  may  need  division,  to  overcome 
the  cavus.  If  the  deformity  be  the  result  of  non-union  of 
the  tendo-Achillis  after  division,  then  the  ends  may  be  cut 
down  upon,  a  portion  removed  from  each,  and  the  ends 
stitched  together.  Little,  in  one  case,  excised  a  portion  of 
the  tendon,  and  of  the  skin  above  and  behind  the  heel,  but 
the  result  was  only  moderately  satis- 
factory. In  another  case  he  subcu- 
taneously  freely  excised  the  extremities 
of  the  divided  tendon,  and  lacerated 
the  insufficiently  developed  interme- 
diate substance,  the  foot  was  then  put 
up  in  extension  and  the  result  was 
favourable.  It  has,  I  believe,  been 
proposed,  if  not  executed,  to  produce 
a  cicatricial  retraction  of  the  skin  of 
the  calf  by  destroying  it  with  the  actual 
cautery  or  nitric  acid,  but  such  reme- 

J  r  IG.  100  — Instrument  for 

dies  seem  severe  as  well  as  uncertain,  the  treatment  of  severe  cai- 
A  properly  constructed  boot  and  sup- caneus- 
port  with  a  stop-joint  at  the  ankle  to 
prevent  flexion,  should  be  worn  during  the  day,  and  the 
universal  Scarpa  at  night.  The  heel  of  the  boot  should 
be  high,  and  elastic  bandages  should  pass  from  the  pieces 
encircling  the  leg,  to  the  heel,  so  as  to  overcome  flexion. 
Passive  motions,  massage,  etc.  are  of  value  in  the  early 
stages. 

Excision  and  suture  of  parts  of  elongated  ten- 
dons.— This  is  the  deformity  in  which  this  operation  is 
most  often  called  for,  but  it  may  be  of  service  in  old  para- 
lytic cases  of  the  other  forms  of  club-foot.  I  have  operated 
on  several  occasions  in  different  forms  of  distortion,  and 
can  speak  well  of  the  plan  in  suitable  cases.     An  incision 


224  BODILY    DEFORMITIES. 

is  carefully  made  down  to  the  tendon,  the  sheath  of  which 
is  opened,  and  it  is  then  raised  by  a  blunt  hook  or  spatula, 
and  folded  or  pinched  between  the  fingers  until  a  fold  of 
sufficient  size  to  correct  the  deformity,  is  ascertained.  A 
silver  wire  is  then  passed  through  the  tendon  about  a 
quarter  of  an  inch  above  and  below  the  parts  where  it  will 
be  divided.  This  precaution  prevents  the  tendon  slipping 
away  up  into  its  sheath.  The  ends  are  then  approximated, 
the  ends  of  the  wire  twisted,  and  buried  by  a  few  taps,  into 
the  tendon.  The  parts  are  then  stitched  up,  and  in  a  week 
gentle  motion  may  be  permitted.  I  have  found  this  plan 
more  reliable  than  the  use  of  silk  or  gut  suture,  which 
nearly  always  give  way  and  render  the  operation  futile. 


225 


CHAPTER   XV. 


PES-CAVUS  J    OR,    PLANTARIS  \    AND    PES    PLANUS 

Synonyms.— German,  Hohlfuss  ;  French,  Pied  creux. 

Definition. -In  this  deformity  there  is   increased  con- 
cavity of  the  plantar  arch  with  dorsal  convexity. 

If  an  impression  of  such  feet  be  taken,  it  will  be  found 
that  in  the  milder  cases  the  outer  side  of  the  foot  will  leave 
an  impression,  whereas,  in  the  severer 
forms,  there  is  a  distinct  break  between 
the  heel  impression  and  that  of  the  front 
of  the  foot  (see  figure).  The  way  to 
take  this  impression  is  to  moisten  the 
soles  of  the  feet  in  water  and  let  the 
patient  stand  upon  a  dry  board,  or,  with 
an  ordinary  painter's  brush,  to  ink  the 
sole  of  the  foot  and  let  the  patient  stand 
upon  blotting  paper;  a  correct  view  of 
the  points  of  pressure  on  the  sole  will 
thus  be  obtained  in  all  the  various  forms 
of  foot  deformity. 

Varieties.— It  may  be  congenital  or  ac- 
quired; the  former  being  rare,  and  the 
latter  has  been  sufficiently  described  in  the   chapter  on 

equinus. 

Causes— The  congenital  forms  may  be  due  to  abnormal 
growth  of  the  tarsal  bones,  or  to  contraction  of  the  abductor 

Q 


Fig.  ioi. — Impres- 
sion of  a  cavus  sole. 


2  26  BODILY    DEFORMITIES. 

pollicis  and  plantar  fascia,  but  I  have  seen  only  one  case 
necessitating  their  division.  The  acquired  form  may  follow 
equinus,  and  it  may  also  arise  from  unilateral  lesion  of  the 
cord. 

Pathological  Anatomy.— This  is  little  known  at  pre- 
sent, but  it  would  seem  that  the  deformity,  in  congenital 
cases,  is  due  to  a  primitive  derangement  of  the  tarsal  bones 
and  ligaments,  and  especially  to  the  inner  portion  of  the 
plantar  ligament. 

Symptoms. —In  congenital  cases  which  have  been  left 
untreated,  the  patients  can  walk  with  comfort,  but  in  others 
a  long  walk  produces  tarsalgia.  As  the  points  of  pressure 
are  on  the  heel  and  the  heads  of  the  metatarsal  bones, 
especially  of  the  big  and  little  toes,  corns  and  bursas  are 

apt  to  form  here  and  thus  may  give 

trouble ;  but  independently  of  this, 

in  some  cases  tarsalgia  is  produced 

after  long  standing  and  walking,  so 

that  such  cases  may  be  described  as 

painful  cavus.   In  some  instances  the 

patient  walks  on   the  outer  border 

of   the  foot   and   raises   the    inner 

Fig.  102.- Pes  cavus.   Left     border,  which  is  also  shortened  and 

foot.  somewhat  inverted,  forming  a  cavo- 

varus. 

Treatment.— Any  distinctly  retracted  structures  may  be 

divided  in  old  cases,  especially  if  there  be  tarsalgia,  as  this 

is  often  due  to  altered  articular  pressure,  but  in  the  majority 

of  cases  the  sole  of  the  boot  should  be  well  moulded  and 

fitted  to  the  foot,  so  as  to  take  the  pressure  of  the  body 

weight  on  the  middle  of  the  instep  and  relieve  the  heel  and 

the  metatarsal  joint.     A  splint  with  a  sole-piece,  having  a 

slot  cut  out  on  either    side  of   the  foot,  through  which 

strapping  or  bandages  can  be  passed  over  the  dorsum  of 


PES-CAVUS.  22  7 

the  foot  to  press  it  downwards,  may,  in  some  cases,  after 
sufficient  time,  lengthen  the  sole  of  the  foot  so  as  to  bring 
a  greater  surface  of  it  in  contact  with  the  ground.  It 
should  be  recollected  that  in  this  deformity  the  foot  is  like 
a  bow,  the  bones  forming  the  wooden  part  and  the  plantar 
fascia  and  muscles  forming  the  string,  so  that  if  the  latter 
can  be  permanently  and  actually  elongated  the  deformity 
will  usually  be  much  relieved. 


PES    PLANUS. 

Definition. — This  deformity  is  also  known  under  the 
name  of  spurious  valgus  or  splay-foot,  and  consists  of  a 
depression  of  the  inner  half  of  the  plantar  arch  without 
eversion  of  the  sole.  In  some  cases  of  the  worst  form  the 
case  may  pass  on  to  become  true  pes  valgus,  but  this  is 
very  rare. 

Synonyms—  Flat  or  splay-foot,  spurious  valgus;  German, 
Platte  Fuss  ;  French,  Pied  plat. 

Causes.— This  condition,  like  valgus  proper,  is  generally 
a  statical  distortion,  and  but  very  rarely  is  it  of  nervous 
origin,  except  in  cases  of  spinal  paralysis.  Flat  foot  is 
common  in  some  races,  as  in  negroes  and  in  Jews,  and,  of 
course,  hereditary  in  them  ;  and  it  is  also,  not  unfrequently, 
hereditary  in  some  European  families.  The  feet  of  the 
new-born  are  almost  always  flat,  on  account  of  the  large 
pad  of  fat  in  the  sole,  and  it  is  only  after  they  begin  to 
stand  and  walk,  and  because,  and  in  spite  of  walking,  that 
the  external  part  of  the  arch  becomes  formed. 

The  arch  of  the  foot  is  composed  of  an  outer  and  an 
inner  segment.  The  former  is  made  up  of  the  calcis, 
cuboid,  and  two  outer  metatarsals,  and  its  points  of  contact 
with  the  ground  are  at  the  calcanean  tuberosity  and  heads 
of  the  metatarsals;  the  latter  is  formed  by  the  astragalus, 

Q  2 


228 


BODILY    DEFORMITIES. 


scaphoid,  cuneiforms,  and  three  inner  metatarsals,  and  only 
its  anterior  part,  i.e.,  the  heads  of  the  metatarsals,  touches 
the  ground,  while  its  posterior  part,  viz.,  the  astragalus,  rests 
on  the  os  calcis,  so  that  the  outer  part  of  the  arch  bears 
almost  the  whole  weight  of  the  body,  transmitted  through 
the  astragalus.  The  outer  part  of  this  composite  arch  is 
supported  by  the  plantar  ligaments,  tendons,  and  fascia,  by 
the  plantar  muscles  and  by  the  arrangement  and  strength 
of  its  bones ;  and  the  cause  of  its  sinking  is  to  be  found, 
generally,  in  some  statical  condition,  which  leads  to  altera- 
tion of  the  normal  equilibrium  between  the  body-weight 
and  the  structures  which  support  and  resist  it. 

Seeing  that  the  normal  form   of   the   foot  at  birth   is 
flattened,  and  that  the  arch,  and  especially  its  outer  part, 
is  formed  through  the  process  of  growth 
and  nutrition,  stimulated  by  the  acts  of 
standing  and  walking  ;  it  is  but  natural  to 
conclude  that  pes  planus  is  the  result  of 
some  defect  in  growth,  or  in  the  direction 
of  pressure,  or  in  both;  and  noting  further, 
that  the    hollow    at   the   middle    of   the 
inner  portion  of  the  sole  is  formed  after 
the  development  of  the  outer  section  of 
the  arch,  which  carries  the  inner  up  with 
it,  one  is  prepared  to  see  how  a   flatten- 
ing of  the  outer  arch  precedes  a  lowering 
of  the    inner,    though    the   body-weight 
causing  this  acts  through  the  astragalus, 
which  is  the  hindermost  part  of  the  in- 
ternal segment  of  the  double  pedal  arch. 
Pes  planus  and  pes  valgus  are  distinct 
conditions,  and  not  grades  or  stages  of  the 
same  distortion,  for  in  the  latter  there  is,  in  well  marked 
cases,  raising  of  the  outer  border  and  eversion  of  the  outer 


Fig.  103.  —  Impres- 
sion of  sole  of  flat  foot. 
In  well-marked  valgus, 
the  outer  quarter  or 
even  one-third  does  not 
touch  the  ground. 


PES    PLANUS.  2  29 

part  of  the  sole,  and  not  in  the  former ;  and  the  astragalo- 
scaphoid  joint  is  usually  normal  in  planus,  though  displaced 
and  gaping  in  valgus  ;  and  in  planus  there  is  no  abduction 
of  the  foot  at  the  ankle,  as  in  valgus.  They  may,  however, 
both  be  congenital^  hereditary,  or  acquired,  and  it  will  nearly 
always  be  elicited,  after  careful  inquiry,  that  in  so-called 
acquired  valgus  or  planus  of  adolescents  and  adults,  the 
subject  has  always  had  a  long  flattish  foot,  with  little  elas- 
ticity or  power  of  spring  in  it,  and  that  it  is  only  when 
pain  and  inconvenience  become  urgent  that  they  apply  for 
relief ;  so  that  I  regard  the  antecedent  structural  conditions 
of  such  feet  as  due  either  to  a  persistence  of  the  normal 
flattened  shape  of  the  feet  at  birth,  or  to  changed  or  arrested 
growth,  probably,  in  some  cases,  to  altered  joint  surfaces, 
the  result  of  abnormally  directed  pressure  during  the  ossifi- 
cation period.  The  large  majority  of  cases  occurring  later 
in  life  are,  in  my  experience,  articular,  and  due  to  rheu- 
matism or  gout. 

Symptoms  and  external  appearances.— These  are 
similar  to  those  of  the  milder  cases  of  valgus,  and  consist 
of  inability  to  stand  or  walk  for  any  length  of  time  without 
inconvenience  or  pain  being  produced.  Tarsalgia  is  some- 
times present  and  may  be  due  to  abnormal  pressure  on  the 
joints  or  muscles,  or  it  may  be  neuralgic;  but  the  majority 
of  cases  of  planus  are  more  inconveniences  and  unsightly 
conditions,  than  serious  deformities. 

Diagnosis. — Eversion  of  the  sole,  or  the  formation  of  a 
canoe-shaped  foot  never  occur  in  this  condition,  and  the 
normal  condition  of  the  astragalo-scaphoid  joint  will  also 
serve  to  distinguish  it  from  valgus.  Flat  foot,  the  result  of 
articular  disease  is  always  a  secondary  deformity  and  need 
cause  no  diagnostic  difficulty. 

Treatment.— Massage,  the  use  of  the  sole-plates  and 
boot  described  in  the  chapter  on  valgus,  and  the  avoidance 


230  BODILY    DEFORMITIES. 

of  prolonged  standing,  walking  or  dancing,  are  the  indica- 
tions for  treatment  in  the  majority  of  cases. 

COMPOUND    FORMS    OF    CLUB-FOOT. 

It  will  have  already  been  gathered  that  these  are  the  rule, 
and  that  the  pure  forms  are  the  exception,  whether  in 
congenital  or  acquired  cases ;  but  for  the  sake  of  complete- 
ness, I  will  devote  a  short  space  to  the  exposition  of  those 
deformities  which  have  been  usually  described  as  the  com- 
pound forms  of  club-foot. 

In  these  cases  intermediate  positions  are  assumed,  so 
that  extension  may  coincide  with  abduction  or  adduction, 
as  also  may  flexion.  These  composite  deformities  occur 
often  in  the  direction  of  normal  motion,  but  in  certain 
cases  this  is  not  so,  for  it  may  be  seen  that  the  anterior  part 
of  the  foot  is  deviated  in  one  direction,  while  the  posterior 
is  turned  in  another.  There  will  thus  be  two  chief  varie- 
ties. In  the  first  and  commonest  form  the  foot  is  devi- 
ated in  two  directions,  while  in  the  second  it  is  deviated  in 
three. 

These  deformities  are  named  by  composite  words,  com- 
bining the  typical-varieties.  The  first  part  of  the  word  being 
usually  given  to  that  deformity  which  is  the  more  pro- 
nounced or  the  more  important.  The  four  chief  varieties 
are  the  following : — 

1.  Pes-Equino-varus,  in  which  the  foot  is  in  extension  and 
Eduction.  The  equinus  is  often,  in  congenital  cases,  more 
difficult  to  cure  than  the  varus. 

2.  Pes-Equino-valgus,  in  which  there  is  extension  and 
adduction. 

3.  Pes-Calcaneo-valgus,  in  which  there  is  flexion  and 
Eduction. 

4.  Pes-Calcaneo-varus,  in  which  there  is  flexion  and 
Eduction. 


COMPOUND    FORMS    OF    CLUB-FOOT.  23 1 

In  the  severer  forms  in  which  there  are  three  deviations 
the  names  are  formed  in  a  similar  manner.  It  is  not 
necessary  to  enter  into  the  causes,  symptoms,  prognosis, 
and  treatment,  as  these  have  been  already  sufficiently 
explained,  and  common  sense  will  inform  us  that  in  these 
compound  forms  it  is  necessary  to  combine  the  treatment 
of  the  two  or  three  forms  in  which  the  foot  is  deviated, 
to  effect  cure  or  amelioration. 


232  BODILY    DEFORMITIES. 


CHAPTER   XVI. 

GENU    VALGUM    AND    OSTEOTOMY. 

Definitions.— Genu  valgum  is  a  deformity  in  which,  on 
standing  with  the  knees  extended  and  touching,  one  or  both 
knees  are  directed  inwards  and  the  malleoli  separated ; 
genu  varum  is  the  opposite  deformity,  i.e.,  when  standing 
with  the  malleoli  touching,  the  knees  are  more  or  less 
separated. 

Synonyms. — Latin,  Genu  Introrsum ;  English,  Knock- 
knee,  In-knee ;  Greek,  Esogonyancon ;  French,  Genou 
cagneux,  genou  en  dedans ;  German,  Backerbein,  Xbein, 
Kniebahrer,  Knickbein,  Knieng,  Ziegenbdn,  Schemmelbein. 

Varieties.— It  may  be  single  or  double  whatever  its 
cause,  the  double  forms  being  commonest,  but  the  trauma- 
tic forms  are  usually  unilateral.  It  may  be  congenital  or 
acquired,  and  there  may  be  valgum  of  one  side  and  con- 
secutive accommodative  varum  of  the  other,  or  vice  versa. 
Other  varieties  are  described  in  the  next  paragraph. 

Causes.— Any  of  these  deformities  may  be  either  con- 
genital, rachitic,  atonic,  statical,  spastic,  paralytic,  traumatic, 
arthritic,  senile,  or  inherited ;  and  their  nomenclature  and 
classification  may  be  arranged  according  to  their  aetiology. 
Another  aetiological  classification  is  into  pathological  and 
traumatic,  the  former  includes  all  those  above  given, 
with  the  exception  of  the  traumatic  cases.  Predisposing 
causes   are   to    be  found    in   bad   hygienic   surroundings, 


GENU    VALGUM    AND    OSTEOTOMY.  233 

insufficient  food,  as  regards  quantity  and  quality,  rickets, 
muscular  and  ligamentous  debility,  etc.  Exciting  causes 
are  to  be  sought  in  errors  in  the  mode  of  standing, 
unequally  distributed  pressure,  the  carrying  of  weights 
on  the  head  or  back,  producing  flat-foot  and  secon- 
dary genu  valgum  or  vice  versa.  Mickulicz  considers  the 
hyper-extension  of  the  legs  on  the  thighs  which  occurs  in 
rickety  subjects  at  the  end  of  extension,  and  permits  in- 
creased rotation  of  the  tibia  outwards,  as  a  pathological 
result  rather  than  a  cause.  Young  bricklayers,  and  especi- 
ally bakers,  who  carry  heavy  loads  of  bread  and  also  work 
for  hours  in  a  warm  moist  atmosphere,  which  is  relaxing  to 
the  tissues,  often  are  affected  by  it. 

The  ato7iic  cases  are  due  to  muscular  and  ligamentous 
debility,  and  possibly  to  some  nerve  debility  also,  by  which 
the  muscles  are  not  kept  in  a  sufficiently  tonic  condition ; 
the  rachitic  are  due  to  changes  chiefly  in  the  direction  of 
overgrowth  in  a  downward  or  inward  sense,  or  both,  of  the 
internal  femoral  condyle,  with  or  without  curvature  of  the 
shaft,  and  in  several  cases  changes  are  also  found  in  the 
head  of  the  tibia.  In  well  marked  rachitic  cases  the  joint 
will  frequently  be  found  loose  and  the  tibia  rotated  on  the 
femur.  In  other  cases  there  will  be  an  appearance  of  rota- 
tion, on  account  of  the  tibial  diaphysis  being  united  to  its 
upper  extremity  at  an  angle  which  is  open  externally,  and 
also  because  the  tibial  shaft  is  twisted  inwards  so  that  its 
crest  is  directed  somewhat  inwards.  A  bony  spiculum  or 
process  is  often  present  at  the  upper  and  inner  part  of 
the  tibia  near  the  insertion  of  the  internal  lateral  liga- 
ment. 

The  pathogenesis  of  most  of  the  other  forms  of  genu 
valgum  and  varum,  as  well  as  of  those  just  given,  has  been 
the  cause  of  considerable  difference  of  opinion  among 
surgeons   of    late  years.       These  various  views    may  be 


234  BODILY    DEFORMITIES. 

arranged  under  three  heads  viz  :  i.  The  ligamentous  theory; 
2.  The  muscular;   3.  The  osseous. 

The  ligamentous  theory  was  supported  by  Stromeyer, 
Gue'rin,  Blasius,  &c. ;  but  two  opposite  views  were  held  by 
its  supporters.  Some  considered  that  the  internal  lateral 
ligament  was  relaxed  primarily,  so  that  there  was  a  looseness 
on  the  inner  side  of  the  joint,  allowing  the  inner  condyle 
to  overgrow  laterally  and  also  downwards,  because  of  the 
gap  permitted  between  it  and  its  corresponding  tibial  sur- 
face. Others  thought  that  the  external  lateral  ligament  was 
primarily  at  fault,  being  shortened,  and  the  pressure  thus 
produced  on  the  outer  condyle  and  corresponding  articular 
surface  of  the  tibia,  caused  their  atrophy,  or  rather,  defici- 
ency of  normal  growth,  while  the  inner  portions  of  the  joint 
had  more  play  to  develop.  Atrophy  of  the  outer  section 
of  the  joint  is  also  the  result  of  relaxation  of  the  internal 
lateral  ligament.  To  the  former  viewT  it  has  been  objected, 
that  the  relaxation  of  the  internal  lateral  ligament  is 
secondary  to  the  changes  in  the  bones ;  and  to  the  latter, 
that  the  external  lateral  ligament  retracts  to  accommodate 
itself  to  the  altered  position  of  the  articular  surfaces  on  the 
outer  side  of  the  joint,  and  therefore,  this  shortening  is  also 
secondary,  and  moreover,  that  there  are  cases  in  which  no 
shortening  of  the  ligament  can  be  made  out. 

The  muscular  theory  is  also  divisible  into  two  opposing 
views.  The  one  attributes  genu  valgum  to  shortening  of 
the  biceps,  popliteus  and  tensor  fasciae  latse ;  the  other 
considers  the  deformity  to  be  due  to  relaxation  of  these 
structures.  Duchenne,  Bonnet,  Verneuil,  Gue'rin,  Little, 
Adams,  Brodhurst  and  others  have  supported  one  or  other 
of  these  views,  but  not,  so  far  as  I  am  aware,  to  the  exclu- 
sion of  osseous  changes,  whether  primary  or  secondary. 
The  supporters  of  this  theory  maintain  that  there  is  a 
primary  contraction ;  then  a  retraction   of  the  muscles  on 


GENU    VALGUM    AND    OSTEOTOMY.  235 

the  outer  side  of  the  joint,  and  that  the  bone  changes,  if 
present,  are  secondary.  The  objections  to  this  view  are, 
that  in  many  cases  no  shortening  or  tension  of  the  external 
muscles  can  be  made  out,  and  that  in  those  cases  in  which 
it  exists,  it  is  secondary.  Paralytic  cases  are  of  course 
explanable  by  this  theory,  i.e.,  lack  of  supporting  power  in  the 
muscles,  and  of  tone  in  the  ligaments,  and  not  by  the 
antagonist  theory  of  which  I  have  spoken  in  the  chapter  on 
scoliosis.  In  these  cases,  and  they  are  common  in  infantile 
paralysis,  nearly  all  the  muscles  are  paralysed,  so  that  there 
are  no  active  antagonists  to  produce  the  distortion. 
Verneuil  admits  another  set  of  muscular  cases,  occurring 
about  the  age  of  puberty  until  the  age  of  20,  in  which  he 
says  that  the  muscles  of  the  inner  side  of  the  thigh  are 
atrophied,  while  the  biceps  is  contracted. 

The  osseous  theory  attributes  genu  valgum  and  varum  to 
primary  changes  in  the  lower  epiphyses  of  the  femur,  or, 
to  the  lower  portion  of  its  diaphysis,  including,  in  some 
cases,  the  upper  end  of  the  tibia.  These  bony  changes 
may  be  due  to  rickets,  whether  infantile,  adolescentium,  or 
senile ;  or  to  other  local  inflammatory,  or  general  osse- 
ous changes  leading  to  hypertrophy  of  the  inner  part  of 
the  joint.  In  these,  as  in  other  cases,  there  may  be 
atrophy  of  the  outer  portion  of  the  joint,  or  this  may  be 

normal. 

Of  recent  years  Annandale,  Ogston,  Chiene,  McEwen, 
Barwell  and  other  surgeons,  have  acted  chiefly  on  the 
belief  that  the  mam  change — whether  primary  or  secon- 
dary—was in  the  bones,  and  mostly  at  the  lower  end  of  the 
femur.  Oilier  proved  by  his  experiments  the  influence 
that  traumatic  inflammation  of  the  epiphysial  cartilage  had 
on  the  growth  of  the  bone.     Mellet  in  1835*  mentioned  the 

*   "Manuel  Pratique  d'Orthopsedie." 


236  BODILY    DEFORMITIES. 

deformity  of  the  condyles  and  thought  this  change  to  be 
primary,  and  Oilier,  Gosselin,  Tillaux,  Delore,  and  others, 
agree  with  this  view.  Seeing  that  the  commonest  bony 
change,  at  the  age  at  which  knock-knee  is  frequent,  is 
rachitic,  it  has  been  concluded  that  all  these  cases  were  due 
to  that  cause.  But  condylar  deviation  may  be  caused  by 
curvature  of  the  lower  part  of  the  femur,  whether  this 
curve  be  convex,  out  or  inwards,  and  in  most  cases  which 
I  have  seen,  this  change  in  the  femur  was  associated 
with  other  evidences  of  rickets ;  but  in  some  of  those 
cases  in  which  such  other  evidence  was  lacking,  the 
hardened  and  dense  condition  of  the  bones  met  with  while 
I  was  operating  confirmed  the  view  previously  formed  as 
to  the  localization  of  rickets  in  these  cases.  In  a  few 
instances  of  marked  deformity,  I  have  found  the  bones 
quite  soft,  cutting  like  dry  cheese. 

The  osseous  theory  is  not  necessarily  confined  to  rachitic 
cases  only,  for  putting  aside  osteomalacia,  arthritis  deformans, 
and  the  rarer  forms  of  bone  change,  it  is  known  that  injury 
or  disease  in  the  neighbourhood  of  joints,  in  growing 
people,  may  produce  changes  in  the  epiphyses,  which  being 
aggravated  by  the  pressure  of  the  body  in  walking,  or  in 
the  various  vocations  of  life,  may  lead  to  abnormal  growth, 
in  the  direction  of  least  pressure,  and  thus  produce  the 
deformity,  while  there  is  arrested  growth  on  the  side  of 
greatest  pressure.  Gosselin  and  Oilier  hold  the  view  that 
there  is  defective  growth  of  the  external  condyle  due  to 
premature  inflammatory  synostosis  of  the  outer  part  of 
the  epiphysial  cartilage,  caused  by  excess  of  pressure  on 
it.  Verneuil  and  others  have  drawn  attention  to  the  fact 
that  in  several  cases  the  upper  part  of  the  tibia  is  similarly 
affected,  and  I  have  seen  not  a  few  cases  in  which  the 
internal  tibial  tuberosity  was  enlarged  and  the  external 
smaller  than  natural.     It  will  thus  be  seen  that  there  are 


GENU   VALGUM    AND    OSTEOTOMY.  237 

two  main  conditions  of  bone,  rachitic  and  inflammatory, 
which  are  appealed  to,  and  with  reason,  n  support  of  the 
osseous  theory. 

There  are  certain  objections  to  this  theory  worthy  of 
note.  For  instance,  in  cases  occurring  in  quite  young  chil- 
dren it  has  too  often  been  assumed  that  the  bony  defor- 
mity was  of  a  rachitic  nature,  even  when  there  were  no  other 
evidences  of  rickets  ;  so  that  if,  in  such  cases,  the  primary 
cause  was  rickets,  it  must  have  been  of  a  purely  local  nature, 
an  uncommon,  though  not  at  all  an  improbable,  hypothesis. 
It  may  also  be  urged,  that  though  there  be  no  appreciable 
evidences  of  rickets  elsewhere,  the  leg  manifestation  is  its 
first  indication,  and  shows  itself  in  the  parts  most  weakened 
from  use,  viz.,  in  the  lower  limbs.  Of  this  I  am  sure, 
that  I  have  seen  such  cases,  but  I  do  not  pretend  to  say  that 
they  are  the  rule. 

With  regard  to  the  supposed  inflammatory  epiphysial 
changes,  it  may  be  said  that  children  suffer  from  many 
hurts,  sprains,  &c,  in  their  tumbles,  and  that  this  traumatism, 
through  being  severe,  or  by  affecting  a  delicate  or  predis- 
posed child,  would  cause  an  epiphysitis;  but  seeing  that 
genu  valgum  and  varum  are  generally  devoid  of  pain, 
whereas  epiphysitis  is  generally  a  painful  affection,  it  would 
lead  us  rather  to  the  view  that  there  is  no  inflammatory 
change,  or  that  if  there  be,  it  must  be  of  a  chronic  or  latent 
character.  I  have  asked  in  many  cases  if  any  so-called 
growing  fiaifis  were  at  any  time  present,  and  more  often 
than  not  have  been  answered  in  the  negative.  My  view  of 
those  cases  occurring  in  children  and  adolescents,  in  which 
the  bone  deformity  is  well  marked,  is,  that  from  some  un- 
known and  at  present  unascertained  cause,  there  has  been 
an  altered  nutrition  in  the  epiphyses  of  one  or  both  bones 
forming  the  knee  joint,  and  that  this  change  is  oftenest 
primary,  and  that  the  contracted  state  of  the  biceps  and 


238  BODILY   DEFORMITIES. 

internal  lateral  ligament,  if  present — which  in  my  experience 
is  anything  but  the  rule — is  secondary. 

I  think  all  will  agree,  that  any  of  the  theories  men- 
tioned are  too  exclusive  to  explain  the  varying  phenomena 
met  with  in  studying  a  large  number  of  cases  of  these 
deformities.  Genu  valgum  is  not,  as  a  rule,  the  result  of 
but  one  cause,  originating  invariably  in  only  one  set  of 
structures  ;  but  is  frequently  due  to  a  series  of  causes,  some 
of  which  are  primary  and  of  more  importance  than  the  rest, 
and  of  these  my  experience  has  taught  me  that  the  bony 
cases  are  of  more  frequent  occurrence  than  the  atonic  or 
those  due  to  muscular  and  ligamentous  weakness. 

Seeing  that  in  the  bony  cases  the  deformity  is  due  to 
overgrowth  and  elongation  of  the  internal  condyle,  with  or 
without  overgrowth  and  curvation  of  the  lower  and  inner 
portion  of  the  femoral  shaft  (Mickulicz),  with  consequent 
twisting  out  of  the  condyles  (McEwen),  or  of  the  outer  and 
lower  part  of  the  diaphysis  of  the  former  (Delore),  with,  in 
some  cases,  corresponding  changes  in  the  upper  end  of 
the  tibia  (which  some  consider  primary),  it  remains  to 
explain  the  probable  mechanism  by  which  the  distortion  is 
produced  in  the  atonic  cases.  To  do  this  satisfactorily  a 
little  space,  must  be  devoted  to  the  consideration  of  modern 
views  as  to  the  normal  anatomy  of  the  knee  joint. 

In  the  normal  joint  there  can,  I  think,  be  no  doubt  that 
the  internal  condyle  is  longer  than  the  external,  so  that  if 
the  femora  were  not  inclined  inwards  at  their  lower  ends 
the  femoro-tibial  articulation  would  be  oblique  from  with- 
out down,  instead  of  being  practically  transverse.  This 
inward  inclination  is  due  to  the  wide  separation  of  the 
femoral  heads  at  the  pelvis,  and  is  necessitated  in  order  to 
preserve  the  line  of  gravity  in  its  proper  position.  Its 
amount  depends  on  the  width  of  the  pelvis  and  on  the 
length  of  the  femora,  and  these  differ  not  only  in  the  sexes, 


•      GENU    VALGUM    AND    OSTEOTOMY.  239 

but  in  different  individuals  of  the  same  sex.  It  has  not  yet 
been  pointed  out  that  the  law  of  asymmetry  may  be  an 
important  factor  in  the  genesis  of  the  statical  forms  of  these 
deformities.  I  see  no  great  difficulty  in  attributing  some  of 
these  cases  to  the  want  of  symmetry  on  the  two  sides  of 
the  body,  so  that  the  femur,  which  originally  was  somewhat 
longer  and  heavier  than  its  fellow,  has,  through  excess  of 
accommodative  strain,  gradually  become  more  valgoid. 
It  may  be  objected,  that  if  this  view  were  true,  females 
ought  to  suffer  more  than  males,  being  naturally  more  valgoid 
at  the  knee,  and  I  would  reply,  that  I  am  not  sure  that 
they  do  not ;  for  women  are  very  apt  to  conceal  any 
deformity,  though  I  admit  that  we  see  the  deformity  more 
often  in  boys  than  in  girls.  This  can  be  explained  by  the 
fact  that  boys  grow  not  only  relatively,  but,  also,  I  am 
inclined  to  think,  absolutely,  faster  than  girls,  and  the 
former  are  more  exposed  to  the  action  of  causes  which  could 
take  advantage  of  any  predisposing  circumstance.  I  do 
not  claim  that  the  law  of  asymmetry  will  serve  to  explain 
all  cases,  but  I  venture  the  hypothesis  as  a  tenable  one, 
when  other  better  known  causes  are  shown  to  be  absent. 
We  know  that  when  one  leg  becomes  shorter  than  the  other 
from  some  pathological  reason,  the  long  one  may  become 
either  valgoid  or  varoid  according  to  the  position  most 
suitable  to,  and  most  assumed  by,  the  patient,  but  the  above 
explanation  of  this  fact  has  not  been  previously  alluded  to. 
It  must  also  be  clearly  apprehended,  that  the  ordinary  line 
of  body  weight-pressure  through  the  middle  of  the  lower 
tibial  articulation,  is  taken  from  a  perfectly  formed  limb,  and 
how  few  are  perfectly  formed  ?  I  am  sure  that  in  both 
general  and  special  pathology,  sufficient  regard  has  not  been 
paid  to  the  fact  that  the  majority  of  individuals  are  any- 
thing but  perfectly  formed,  even  in  their  normal  condi- 
tion;  and    that  these   primary  imperfections  may  be  im- 


240  BODILY    DEFORMITIES. 

portant    predisposing    causes   for   various    maladies    and 
deformities. 

In  the  normal  state,  on  standing  with  the  feet  together, 
the  femur  and  tibia  form  an  angle  open  externally,  the 
femur  being  inclined  inwards,  while  the  tibia  is  almost 
vertical,  and  the  greater  the  width  of  the  pelvis  the  less 
open  becomes  the  femoro-tibial  angle,  for  the  inward  pro- 
jection of  the  lower  end  of  the  femur  is  more  marked. 
This  is  very  noticeable  in  well  developed  women,  but  is 
partly  concealed  by  the  greater  relative  amount  of  subcu- 
taneous fat  in  the  thighs,  especially  at  their  upper  and 
inner  parts. 

Degrees. — In  atonic  statical  cases  (i.e.  those  caused 
through  long  standing,  walking,  and  wrongly  directed  pres- 
sure in  delicate  subjects)  there  are  commonly  three  stages  and. 
grades  of  the  deformity.  In  the  Jirst  stage,  there  is  stretching 
of  the  internal  lateral  ligament  through  the  altered  direction 
of  the  axis  of  pressure  towards  the  inner  side  of  the  joint,  and 
Mickulicz  has  found  this  internal  ligament  tense  and  hyper- 
trophied,  instead  of  relaxed,  and  Owen  and  Linhart  have 
made  similar  observations.  The  last  named  observer 
found  the  external  lateral  ligament  lengthened,  but  this  is 
quite  exceptional.  Probably  the  crucial  ligaments,  espe- 
cially the  posterior  portion  attached  to  the  internal  condyle, 
is  also  stretched.  Lannelongue  has  found  the  posterior  cru- 
cial rudimentary,  and  anterior  absent.  If  the  patient  now 
come  under  observation,  the  case  would  be  considered  a 
mild  one.  In  the  second  stage  the  tendon  of  the  biceps,  the 
external  lateral  ligament  and  the  ilio-tibial  band  of 
the  fascia  lata,  all  on  the  outer  side  of  the  joint,  become 
contracted,  and  this  serves  to  increase  the  deformity.  In 
the  third  stage  bony  changes  become  more  noticeable.  The 
internal  condyle  becomes  enlarged  laterally,  also  elongated 
and  separated  from  the  tibia ;  and  if  the  ligaments  on  the 


GENU    VALGUM    AND    OSTEOTOMY.  24 1 

inner  side  be  very  lax,  a  depression  can  be  distinctly  felt 
between  the  femur  and  tibia  ;  but  as  a  rule  the  enlargement 
of  the  inner  condyle  fills  the  gap  that  would  otherwise 
exist  between  the  bones,  or  the  internal  tibial  tuberosity 
enlarges  and  fills  the  gap,  but  this  is  exceptional,  in  my 
experience.  The  external  condyle  and  outer  tuberosity  of 
the  tibia,  having  to  bear  the  body  weight,  become  pressed 
together,  and  either  atrophy  or  cease  to  grow,  and  thus  serve 
to  accentuate  the  deformity. 

Morbid  Anatomy. — Much  of  this  has  been  given  in 
the  preceding  paragraphs,  but  a  complete  summary  of  exist- 
ing knowledge  will  be  useful.  The  most  pronounced  change 
is  in  the  bones  forming  the  knee  joints,  and  especially 
at  the  lower  end  of  the  femur,  the  internal  condyle  of 
which,  or  the  lower  third  and  inner  part  of  its  shaft,  is 
overgrown  and  curved  inwards  and  downwards.  The  in- 
ternal condyle  is  often  really  elongated,  though  in  several 
cases  it  is  displaced  downwards  by  the  lengthening  of  the 
inner  side  of  the  femur.  In  rachitic  cases,  there  are 
often  found  internal  or  external  curvature  of  the  femur 
and  tibia  at  the  lower  or  upper  ends,  and  sometimes  in  both. 
Sometimes  there  is  an  external  curve  at  the  lower  third 
of  the  femur,  the  concavity  of  which  is  internal,  and  the 
effect  of  this  is  to  cause  a  difference  in  the  relative  lengths 
of  the  condyles.  The  lower  epiphysis  of  the  femur  may 
also  be  twisted  or  rotated  out  (Volkmann).  The  external 
condyle  is  flattened  and  shortened,  and  the  articular  carti- 
lages are  hypertrophied  on  the  outer,  and  atrophied  on  the 
inner  side  of  the  joint,  and  atrophic  changes  have  also  been 
observed  in  the  outer  inter-articular  cartilage.  The  internal 
articular  surface  of  the  tibia  is  a  little  larger  and  shallower 
than  normal,  and  its  internal  tuberosity  may  be  enlarged. 
This  bone  is,  in  some  severe  rachitic  cases,  rotated — gene- 
rally inwards — so  that  the  tibial  crest  is  directed  somewhat 

R 


242  BODILY    DEFORMITIES. 

inwards  and  is  often  curved  at  its  upper,  but  more  often  at 
its  lower,  part.  Rotation  outwards  of  the  tibia  is  common 
in  these  cases,  and  an  osseous  spiculum  is  frequently  present 
near  the  insertion  of  the  internal  lateral  ligament,  in  bad 
rachitic  examples.  The  condition  of  the  tendons  and  liga- 
ments on  the  outer  side  of  the  joint  are  secondary  and 
have  already  been  described,  and  the  other  muscles  moving 
the  knee  are  sometimes  not  well  nourished,  and  are  thinner 
and  longer  than  normal. 

In  certain  non-rachitic  cases   occurring  about   puberty, 
Mickulicz  has  shown  that  the  femoral  and  tibial  epiphyses 


Fig.  104. — Diagram  of  a  normal  and  abnormal  femur,  lower  end.  (After  Mickulicz. 

nearly  preserve  their  normal  length,  and  that  the  changes  in 
their  position  are  due  to  pathological  changes  in  the  epi- 
physial cartilage.  He  found  the  internal  portion  of  the 
lower  femoral  epiphysis  thicker  than  the  outer,  and  considers 
that  "  the  alteration  in  length  on  the  inner  side  of  the 
femur  arises  not  from  alteration  of  the  epiphysis,  but  is 
confined  to  the  lowest  part  of  the  diaphysis  "  as  represented 
in  the  adjoining  figures.  A  corresponding  deviation  of  the 
tibial  diaphysis  is  also  present  in  some  cases.  Microscopic 
examination  showed  that  the  cartilages  were  in  a  similar  con- 
dition to  that  found  in  rickets,  so  that  these  cases  furnish 
evidence  in  support  of  the  purely  local  occurrence  of  rachitic 


GENU    VALGUM    AND    OSTEOTOMY.  243 

changes,  and  serve  to  explain  the  occurrence  of  the  adoles- 
cent and  senile  forms  of  the  distortion.  It  must  however 
be  mentioned  that  the  dissections  of  Chiari  tend  to  show 
that  there  is  real  elongation  of  the  internal  condyles,  and  the 
autopsies  of  de  Santi,  Guenot,  and  Lannelongue*  have 
proved  this  to  exist  in  their  cases. 

It  will  thus  be  seen  that,  in  many  cases,  the  old  view  at- 
tributing genu  valgum  to  elongation  of  the  internal  con- 
dyle, is,  in  part,  correct,  though  researches  show  that  the 
elongation  is  apparent  rather  than  to  any  great  extent  real, 
for  it  is  pushed  and  displaced  downwards  by  overgrowth,  in 
length,  of  the  inner  side  of  the  lower  third  of  the  femur. 
For  practical  purposes,  it  being  shown  that  in  the  majority 
of  such  cases  the  internal  condyle  is  lower  than  the  outer, 
however  produced,  pathology  may  be  disregarded.  I  think 
that  the  explanation  of  this  curve,  convex  inwards,  met  with 
in  several  rachitic,  and  in  some  non-rachitic  cases,  is  to  be  ex- 
plained by  the  downward  growth  of  the  shaft  being  checked 
by  the  vertical  pressure  at  the  knee  in  standing  and  walking, 
and  so  growth  takes  place  laterally,  and  causes  broadening  of 
the  internal  femoral  tuberosity  and  of  the  lower  end  of  the 
shaft.  The  vertical  pressure  also  causes  the  young  cartilage 
of  the  femur  to  yield  inwards  in  the  direction  of  least  resist- 
ance, and  that  of  the  upper  part  of  the  tibia  to  overgrow 
internally,  and  to  yield  at  the  junction  of  the  shaft  with  the 
tuberosities,  so  as  to  form  an  angle  open  externally. 

Symptoms. — The  subjective  symptoms  are  few,  and  vary 
with  the  degree  and  cause  of  the  deformity  and  nature  of 
the  case.  Pain  at  the  inner  side  of  the  knee,  which  may 
be  increased  on  pressure,  is  sometimes  complained  of,  but 
is  not  often  severe.  The  great  complaint  is  that  of  soon 
becoming  fatigued,  and  inability  to  stand  for  any  time,  or 
to  walk  any  distance.      The  objective  symptoms  are  pro- 

*  "Peyre,  These  de  Paris,  1879." 

R    2 


244  BODILY    DEFORMITIES. 

nounced  in  two  directions  :  in  the  gait  of  the  patient,  and 
in  the  aspect  of  the  deformed  limbs.  The  gait  is  character- 
istic. The  knees  being  slightly  flexed,  and  the  inner  con- 
dyles touching  or  overlapping,  the  legs  have  to  be  separated 
at  the  knees  to  permit  of  progression,  and  at  each  step  the 
knees  yield  internally,  producing  a  sort  of  half  roll,  half 
jerk.    In  unilateral  cases  this  peculiar  gait  is  diminished  by 


Fig.  105.— To  show  the  shortening  caused  by  genu  valgum.     Taken  from  a  lad 
on  whom  I  subsequently  performed  diaphysial  osteotomy. 

inclination  of  the  hip  to  the  affected  side,  and  by  slightly 
flexing  the  thigh  on  the  sound  side,  the  inequality  of  the 
limbs  is  remedied.  In  double  genu  valgum,  sufferers  dimin- 
ish the  characteristic  walk  by  flexing  both  legs. 

Genu  valgum  is  more  common  in  boys  than  girls,  on 
account  of  their  more  active  habits,  and  of  their  mode  of 
employment  among  the  poorer  classes.  It  developes  more 
especially  at  two  periods,  viz.,  from  the  second  (when  the 
child  has  walked  for  a  time),  to  the  fourth  year,  and  from 
puberty  to  sixteen  or  seventeen  years,  and  may  increase 


GENU    VALGUM    AND    OSTEOTOMY.  245 

until  the  period  of  growth  is  over,  or,  in  rachitic  cases,  when 
this  process  has  been  completed. 

The  affected  leg  or  legs  will  be  found  to  be  directed  down 
and  outwards,  so  that  on  standing  there  is  a  considerable 
gap  between  the  malleoli.  Often  there  is  a  rotation  of  the 
tibia  outwards,  but  in  some  severe  cases  I  have  seen,  it  has 
been,  as  before  mentioned,  rotated  inwards,  so  that  the 
anterior  leg  muscles,  instead  of  presenting  on  the  outer, 
were  on  the  anterior  aspect  of  the  leg.  There  is  a  marked 
projection  at  the  inner  side  of  the  knee,  in  most  cases,  and 
this  is  due  to  the  overgrown  internal  femoral  condyle,  and 
also  in  some  cases  to  the  overgrown  upper  part  of  the  tibia. 
The  patella  is  often  carried  out  and  articulates  with  the 
front  of  the  external  condyle,  and,  in  the  worst  cases,  it  is 
dislocated  quite  outwards.  The  movements  of  the  joint 
are  free,  and  in  consequence  of  the  laxity  of  the  ligaments, 
in  some  of  the  cases,  and  especially  the  rickety  ones,  there 
is  considerable  active  and  passive  lateral  motion  permitted  ; 
abduction  and  external  rotation  of  the  tibia  are  also  in- 
creased, as  is  also  extension,  in  several  cases.  Hueter  ex- 
plains this  in  the  following  way.  There  is,  on  the  anterior 
aspect  of  each  condyle,  a  triangular  facet  (described  by 
Goodsir  and  Henle)  just  below  the  patellar  facet,  and  ex- 
tension ceases  when  these  facets-  are  in  contact  with  the 
glenoid  tibial  surfaces,  through  the  intervention  of  the 
inter-articular  discs.  In  genu  valgum,  the  facet  on  the 
external  condyle  is  more  hollow  and  depressed,  and  thus 
permits  a  greater  amount  of  extension. 

A  very  remarkable  fact  is,  that  of  the  almost  complete  dis- 
appearance of  the  deformity  when  the  knee  is  flexed  to  a  right 
angle.  Several  explanations  have  been  offered.  Lannelongue 
attributes  it  to  the  absence  of  the  crucial  ligaments,  permitting 
rotation  and  perfect  application  of  the  leg  to  the  thigh  during 
flexion  \  but  this  has  not  been  shown  to  be  the  rule  in  knock- 


246 


BODILY    DEFORMITIES. 


a 

ri 


U 


knee,  and  will  not  suffice.     Guenot  thinks  that  the  increase 
of  the  internal  condyle  is  only  in  its  length,  and  not  antero- 
posteriorly,  and  that  in  flexion  the  tibial  articular  surfaces 
come  in  contact  with  the  posterior  surfaces  of  the  femoral 
condyle,  and  at  this  point  the  condylar  surfaces  are  normal. 
Gerard's  explanation  is  hypothetical.     He  thinks  that  the 
posterior  part  of  the  internal  condyle  is  less  prominent,  or 
that  the  corresponding  part  of  the  external  is  more  prominent. 
Busch's  explanation  is  the  most  satisfactory  on  anatomical 
and  mechanical  grounds.     He  says  it  is  due  to  the  down- 
ward  displacement    of    the    internal    condyle   causing   an 
obliquity  of  the  articular  line,  and  a 
consequent  oblique   axis    of  rotation. 
If,    as   in  the  accompanying  figure,  a 
foot-rule,   with   a    Charnier's   joint   at 
right  angles  to  its.  axis,  be  moved,  the 
movements   of  flexion   and    extension 
will  be  in  the  same  plane.    If  the  joint 
be   obliquely  placed    the  rule  will  be 
straight    in    complete  extension,    but 
deviates  more  and  more  with  increasing 
flexion   from  the  early   flexion   plane. 
But  if    the   two  limbs   of  the  rule 
be  joined  at  an  angle  in  complete  ex- 
tension, and  this  be  gradually  flexed, 
then  this  angular  bend  will  diminish  with  increasing  flexion, 
and  will  disappear  when  flexion  has  reached  1800.     It  is 
this  mechanical  condition  which  causes  the  disappearance 
of  valgum  with  increasing  flexion,  and  though  the  mechani- 
cal conditions  are  more  complicated  in  knock-knee,  than  in 
a  simple  rule,  it   is  the   obliquely  directed  axis  of  rotation 
which  is  the  chief  factor  in  the  disappearance  of  the  valgus 
in  increasing  flexion. 
Complications. — In    severe    or    old    standing    cases, 


H 


Fig.  106. — Diagram  to 
explain  the  disappearance 
of  genu  valgum  on  flexion. 


GENU    VALGUM    AND    OSTEOTOMY.  247 

secondary  deformities  result.     These  are  shown  in  the  feet, 
spine,  and  opposite  leg.     The  former  may  be  in  temporary 
varus  or  valgus.     In  the  latter  the  toes  are  generally  turned 
out,  and  vice  versa  in  the  former,  and  these  distortions  result 
from  the  patient's  efforts  to  preserve  the  centre  of  gravity  and 
to  minimise  the  effects  of  the  deformity.    The  varied  position 
may  be   due  to  efforts  to  overcome   the  primary  valgoid 
tendency,  and  may  result  from  trying  to  keep  the  entire  sole 
applied  to  the  ground.  Scoliosis,  either  temporary  or  perma- 
nent, may  occur,  and  the  severity  and  permanence  of  it  will 
depend  on  the  deviation  and  nature  of  the  primary  defor- 
mity.    If  only  one  leg  be  affected,  or  if  one  leg  be  shorter 
than  the  other,  in  double  cases,  a  not  uncommon  occur- 
rence, secondary  scoliosis  is  apt  to  form,  and  the  primary 
lumbar  curve  will   be  in  the  direction  of  the  shorter  limb. 
In  some  severe  cases  of  single  genu  valgum  a  compensatory 
or  accommodative  genu   varum   of  the 
opposite    limb    occurs,    and     I   have 
operated  on  several  such  with  perfect 
correction  of  both  deformities.     The 
possibility  of  these  deformities  develop- 
ing   in    some    cases     simultaneously, 
should  not  be  forgotten.     This  defor- 
mity, rendering   the  sufferer   weak  in 
his  supports,  exposes  him  to  injuries  of 
the  knee ;  and  also  in  some  instances       FlG  10Jm  _  Severe  vai- 
to   dry  or  effusive  articular   mischiefs.    ^hynsiarjsrtUeotoCmye. 
Bursse  may  also,  in  severe  cases,  form 
at  the  sides  of  the  internal  condyles  through  friction  and 
pressure    The  leg-bones  may  also  yield  in  various  directions 
in  rachitic  cases,  but  chiefly  in  an  anterior  or  internal  direc- 
tion ■   and  if  this  be  extreme,   the  subject   walks   on  the 
inner   side    of  the   foot   and   inner   malleolus,    and    genu 
valgum  may  be  secondary  to  this  condition. 


248 


BODILY    DEFORMITIES. 


Measurement  of  the  Deformity. — The  eye  will  often 
enable  us  to  say  whether  the  case  be  mild,  moderate  or 
severe  ;  but  measurement  will  furnish  accurate  information, 
and  is  valuable  in  showing  us  the  effect  of  treatment.  The 
methods  of  Tillaux  and  Mickulicz  are  unnecessarily  com- 
plicated and  need  not  detain  us.  The  patient  may  be  in 
the  erect  or  recumbent  posture,  (I  prefer  the  latter)  and  the 
knees  touching,  care  being  taken  that  the  patient  do  not 
conceal  some  of  the  deformity  by  internally  rotating  the 
femur.  Then  the  limbs  may  be  measured  on  the  outer  or 
inner  side,  or  on  both.     In  the  former  plan,  a  measuring 


Fig.  108. — Extreme  rachitic  genua  valga  and  curved  tibia. 


tape,  or  a  long  wooden  graduated  measure,  takes  the  length 
from  the  top  of  the  great  trochanter  to  the  tip  of  the  exter- 
nal malleolus  (see  figure),  and  a  hand  rule  measures  the 
height  of  the  angle  opposite  the  knee.  These  measure- 
ments should  be  recorded.  In  the  latter,  an  ordinary  long 
splint,  suitable  to  the  size  of  the  patient,  should  be  accu- 
rately placed  in  the  mid-line,  the  knees  should  be  made  to 
touch  it,  and  the  distance  of  the  malleoli  from  it  accurately 
noted.  To  the  former  plan  it  has  been  objected,  that  the 
angle  formed  by  a  slight  deformity  in  a  long  limb,  will  coin- 
cide with  a  considerable  deviation  in  a  short  one  ;  but   if 


GENU    VALGUM    AND    OSTEOTOMY. 


249 


the  measurements  are  made  on,  and  relate  to,  the  same  sub- 
ject, there  need  be  no  difficulty.  Marchand  and  Terrillon 
proposed  to  measure  the  angle  formed  by  the  femoral  with 
the  tibial  axis  ;  but  this  is  somewhat  difficult,  and  not  neces- 
sary7, as  the  two  methods  just  given  suffice 
for  all  practical  purposes. 

Prognosis. — Since  the  successful  ap- 
plication of  osteotomy  to  these  cases  this 
is  always  favourable.  I  speak  chiefly  from 
my  personal  experience  of  the  operation, 
and  shall  point  out  any  accidents  that 
may  happen,  in  the  ensuing  paragraph. 

Treatment. — This  must  vary  accord- 
ing to  the  severity  of  the  case  and  to 
some  extent  according  to  the  cause.  The 
object  being  to  bring  the  limb  into  a 
normal  position,  the  only  question  is  as  to 
the  best  mode  of  doing  it.  Until  about 
the  last  dozen  years,  no  rapid  methods 
were  known  to,  or  generally  adopted  by, 
surgeons,  and  treatment  was  confined  to 
splinting  and  tenotomy.  Reduction  may, 
now-a-days,  be  accomplished  gradually,  or 
at  once  ;  and  even  in  forcible  manual  or 
instrumental  straightening,  complete  reduction  need  not  be 
attempted  at  once,  but  may  be  done  piecemeal  at  several 
sittings.  The  surgical  treatment  consists  in  the  use  of 
splints,  instruments,  and  in  operative  procedures.  The 
instruments  are  divisible  into  two  kinds  according  to  the 
nature  of  the  case,  i.e.  those  allowing  the  patient  to  walk, 
and  those  for  use  only  when  the  patient  is  in  a  recumbent 
posture.  The  operative  procedures  may  be  divided  into 
five  :  viz.,  1,  tenotomy  and  gradual  reduction ;  2,  forcible 
reduction ;     3,    osteotomy  •    4.,    osteoclasy ;    5,    epiphysial 


Fig.  109. — Diagram 
of  how  to  measure  the 
amount  of  a  genu 
valgum.  The  lines  i 
and  2  indicate  the 
axes  of  the  femur  and 
tibia.     See  text. 


250 


BODILY    DEFORMITIES. 


chrondrotomy.  There  is  external  wound  only  in  tenotomy, 
osteotomy  and  chrondrotomy,  but  the  first  is  subcutaneous 
and  the  second  practically  so. 

In  slight  cases,  relieving  the  limbs  of  the  body  weight,  and 
the  application  of  well-padded  splints  to  the  outer  or  inner 
side  of  the  limb,  will  often  suffice.  Some  surgeons  prefer 
to  act  on  the  inner  side,  using  the  internal  condyle  as  a 


Fig.  iio. — Diagrams  of  a  normal  lower  limb  (middle  figure),  of  a  genu  valgum  (to 
the  left),  and  of  a  genu  extrorsum  (to  the  right).  A  vertical  line  passes  through  the 
head  of  femur  and  middle  of  ankle  joint,  and  a  transverse  one  through  the  knee- 
joints,  showing  the  altered  levels  of  the  internal  and  external  condyles. 


fulcrum,  and  taking  leverage  from  the  malleoli,  thus  gradu- 
ally drawing  the  leg  or  legs  inward.  Others  prefer  applying 
the  splints  on  the  outer  side,  taking  the  fixed  points  at  the 
trochanter  and  external  malleolus,  and  slowly  forcing  the 
knee  outwards,  and  yet  others  apply  splints  to  both  sides  of 


GENU    VALGUM    AND    OSTEOTOMY. 


251 


the  limb.  Similar  results  can  be  obtained,  in  those  who  can 
afford  an  instrument,  by  the  use  of  one  properly  constructed, 
as  shown  in  the  accompanying  figures.  These,  though  admit- 
ting of  knee  flexion,  should  be  kept  rigid  at  that  joint  by 
the  use  of  the  ring-bolt  or  spring-catch,  as  immobilisation  of 
the  knee  has  given  good  results  in  many  cases,  and  patients 


Fig.  hi. —  Instrument 
for  genu  valgum,  with 
perineal  band. 


Fig.  112. — A  lighter 
form  of  genu  valgum  ; 
instrument  with  spring 
catch. 


soon  accustom  themselves  to  walk  fairly  well  even  with  the 
knees  kept  extended.  In  many  of  these  cases  such  methods, 
though  slow,  are  efficient. 

When  there  is  a  viediu??i  degree  of  the  deformity,  and 
especially  when  the  means  just  mentioned  have  failed, 
tenotomy  of  the  biceps  tendo?i  and  possibly  of  the  ilio-tibial 


2^2 


BODILY    DEFORMITIES. 


band,  may  be  called  for,  especially  if  these  be  tense.  Divi- 
sion of  the  external  lateral  ligament  results  in  a  loose  joint, 
and  in  recurrence   of  the  deformity,  if  the  patient  walk 


Figs.  113  and  114. — Mr.  H.  Baker's  instrument  for  genu  valgum,  after  tenotomy,  to 
keep  the  knee  extended  and  prevent  rotation  of  the  leg.  A.  Thigh-trough  ;  B.  Cog- 
wheel;  C.  Knee-band;  D.  Ankle-strap;  F.  Side-wing;  H.  Inside  toe-strap; 
I.  Pad  to  go  between  heel  and  F.  ;  K.  Extension  bar  behind  knee  ;  M.  and  N.  The 
wing-straps.     The  left-hand  figure  shows  the  instrument  applied. 


without  an  instrument.  Langenbeck  and  others  divided 
this  ligament  over  forty  years  ago,  and  the  results  were  very 
unsatisfactory.     Bonnet  and  Guerin  had  also  done  these 


GENU    VALGUM    AND    OSTEOTOMY.  253 

operations  previously.  After  tenotomy  the  limb  is  put  up 
in  the  deformed  position  for  three  or  four  days,  and  then  a 
splint — for  which  the  patient  has  been  previously  measured 
— is  applied,  the  limb  safely  secured  so  as  to  prevent  rota- 
tion, and  by  the  use  of  a  joint  on  the  outer  side,  the  limb 
is  gradually  straightened.  This  process  is  slow,  and  is  often 
interrupted  through  pressure  excoriations.  When  these 
occur,  the   apparatus  must  be  loosened  or    removed,  and 


Fig.  115.— A  case  of  atonic  double  genu  valgum  in  a  girl  aged  nine,  which  was 
cured  by  tenotomy  of  biceps  and  subsequent  use  of  a  genu  valgum  correction  splint. 

This  is  only  one  of  many  similar  cases. 

spirituous  lotions  applied  to  harden  the  skin,  and  to  lessen 
inflammation. 

Tenotomy  of  the  Biceps.— The  patient  lying  on  his 
face  is  told  to  flex  the  limb,  while  an  assistant  gently  resists 
this  motion  with  one  hand,  and  steadies  the  thigh  with  the 
other.  The  tendon  is  thus  rendered  prominent,  and  the 
operator  passes  the  tenotome  vertically  between  the  tendon 
and  the  external  popliteal  nerve  about  an  inch  above  the 
joint,  from  within  outwards  and  towards  the  skin,  while  the 
assistant  is  stretching  the  tendon,  and  directly  he  feels  all 
resistance  gone  he  should  immediately  relax.     The  surgeon 


254  BODILY    DEFORMITIES. 

will  feel  a  gap  between  the  severed  ends  of  the  tendon,  and 
should  keep  his  knife  well  under  control  during  the  opera- 
tion to  prevent  its  coming  through  the  skin.  Not  that  this 
rare  accident  is  serious  to  life,  but  it  is  most  undesirable,  as 
in  unhealthy  subjects  suppuration  may  occur,  and  in  any 
case  a  largish  scar  will  be  left  instead  of  a  mere  punctured 
cicatrix.  The  peroneal  nerve  has  been  divided  in  this 
operation  by  inexperienced  operators,  and  this  was  followed, 
in  some  cases,  by  temporary,  and  in  others,  by  permanent 
paralysis.  Even  experienced  operators  have  met  with  this 
accident,  as  Tamplin  relates  a  case  in  which  he  divided  the 
nerve,  but  the  paralysis  only  lasted  six  to  eight  weeks. 

The  following  indications  may  be  of  service  in  preventing 
this  accident.  After  the  biceps  tendon  has  been  divided, 
the  peroneal  nerve  will  sometimes  be  felt  quite  distinctly 
stretching  along  in  the  neighbourhood  of  the  operation  ;  but 
if  the  patient  be  told  to  flex  the  limb  it  will  be  found,  if 
the  tendon  have  been  properly  divided,  that  no  prominence 
occurs  in  its  course  as  before  the  operation,  and  a  gap  will 
easily  be  felt  between  its  severed  ends.  This  will  suffice 
to  show  that  the  cord-like  structure  is  the  nerve,  and  not 
an  undivided  part  of  the  tendon.  In  case  of  doubt,  the 
assistant  should  extend  the  leg,  and  it  will  be  seen  and  felt, 
in  properly  conducted  cases,  that  the  tendon  has  been 
thoroughly  divided.  If  the  tendon  have  been  transfixed 
and  only  partially  divided,  there  will  be  more  difficulty  in 
differentiating  the  remaining  portion  of  it  from  the  nerve  ; 
but,  it  will  be  observed  that  attempts  to  straighten  the 
limb  are  resisted,  whereas  this  would  not  be  the  case  if  it 
had  been  thoroughly  divided.  If  the  nerve  have  been 
divided,  the  best  course  is  to  put  up  the  limb  in  the  deformed 
position  for  ten  or  fourteen  days,  or  until  such  time  as 
suffices  to  furnish  indications  of  its  functions  being  restored. 
If  union  do  not  take  place  in  a  month,  the  nerve  should  be 


GENU    VALGUM    AND    OSTEOTOMY.  255 

cut  down  on  and  its  end  pared  and  drawn  together  by  catgut 
stitches  passed  through  the  neurilemma.  I  have  adopted 
this  proceeding  in  old  wounds  of  the  forearm  of  many 
months'  standing  and  have  been  successful,  and  other  sur- 
geons have  met  with  a  similar  success  at  much  longer 
intervals.  If,  in  this  operation,  the  tenotome  be  passed  too 
deeply  down  towards  the  bone  the  superior  external  articu- 
lar artery  may  be  wounded,  but  pressure  combined  with  rest 
and  returning  the  limb  to  its  original  position  would  I 
think,  suffice  to  check  this. 

In  mild  and  moderate  cases,  and  even  in  some  severe 
forms,  Hueter  put  into  practice  his  plan  of  curing  by 
altered  position.  As  already  explained,  he  thinks  that 
hyper-extension  of  the  joint  is  often  present  and  as  a 
causative  influence,  so  he  puts  up  the  limb  in  a  semi-flexed 
position  and  keeps  it  so  for  a  considerable  time.  Several 
German  surgeons  have  tried  this  method  without  success 
and  as  it  leaves  the  existing  deformity  untouched,  the 
only  hope  is,  that  pressure  being  taken  off  the  lower  aspect 
of  the  condyles,  the  external  will  be  allowed  scope  to  make 
up  for  its  retarded  development,  while  the  internal  will  only 
grow  very  slightly  if  at  all. 

In  the  third  class  of  cases  in  which  the  deformity  is 
severe  or  of  long  sta?iding,  and  especially  in  rachitic  and 
severe  statical  cases — always  granting  that  the  eburnating 
stage  has  occurred,  or  is  taking  place— we  must  resort  to 
more  radical  measures,  after  giving  a  fair  trial  to  the  means 
already  mentioned.  In  hospital  practice,  where  the  services 
of  children  from  ten  to  fifteen  are  of  great  service  to  their 
parents,  valuable  time  need  not  be  wasted  in  the  further 
trying  of  splinting,  &c,  especially  as  operations  are,  in  my 
own  experience,  which,  as  regards  number  of  operations,  is 
second  only  to  that  of  McEwen,  absolutely  safe.  These 
consist  of— 1.  Forcible  straightening,  the  redressi?ient  brusque 


256  BODILY   DEFORMITIES. 

of  Delore  of  Lyons,  which  may  be  manual  or  instrumental ; 
2.  Osteotomy  and  Osteectomy  ;  3.  of  Osteoclasy ;  and  4. 
Epiphysial  Chondrotomy.  The  joint  has  been  excised  by 
Mr.  Howse  of  Guy's  for  genu  varum  and  valgum,  but  none 
will,  nowadays,  repeat  these  operations. 

Forcible  manual  reduction  is  thus  done  by  Delore. 
The  patient  being  ansesthetised,  the  affected  limb  is  placed 
in  external  rotation,  an  assistant  keeping  the  external 
malleolus  slightly  raised  from  the  table,  and  the  surgeon 
exercises  successive  and  slightly  increasing  pressure-jerks  on 
the  front  of  the  knee,  which  is  upwards,  i.e.,  the  patella  looks 
upwards.  Presently,  cracking  sounds  are  heard,  and  the 
limb  can  be  put  straight.  Tillaux  operates  in  an  opposite 
way,  i.e.,  uses  the  internal  condyle  as  the.  point  cPappui.  The 
limb  is  so  placed  that  the  internal  condyle  rests  on  the  edge 
of  the  table,  properly  protected,  and  the  surgeon  grasps  the 
knee  to  prevent  rotation,  with  one  hand,  while  assistants 
steady  the  thigh  ;  with  the  other,  he  holds  the  leg  just 
above  the  malleoli,  using  it  as  a  lever,  the  internal  condyle 
being  the  fulcrum,  and  the  leg  hanging  beyond  the  table. 
Then  he  exercises  sharp  and  successive  jerks  and  pres- 
sures, on  the  leg,  until  cracking  sounds  are  heard  and  the 
leg  can  be  straightened.  The  time  for  this  varies  in 
different  cases  from  five  to  twenty  minutes.  I  have  had 
cases  which  yielded  fairly  readily,  and  others  which  gave 
great  trouble  before  reduction  occurred.  The  limb  is 
then  put  up  in  gum,  silicate,  or  Paris  plaister,  or  between 
straight  splints,  and  in  most  of  my  cases  an  icebag  was 
applied  over  the  joint.  The  limb  is  kept  quiet  for  from 
three  to  six  months,  then  the  joint  stiffening  is  overcome  by 
passive  motions,  massage,  &c,  and  the  patient  must  only 
be  allowed  to  walk  with  crutches  for  another  year  ;  but,  in 
some  cases,  the  limb  fractures  were  restored  in  six  months. 
In  some  of  my  cases  I  adopted  gradual  forcible  reduction 


GENU    VALGUM    AND    OSTEOTOMY.  257 

at  three  or  more  sittings,  and  Kcenig,  and  others,  have  used 
the  same  method. 

Delore  has  operated  on  200  such  cases,  and  other  sur- 
geons' cases  must  bring  the  total  up  to  300  at  least,  and 
only  two  deaths  have  occurred,  so  far  as  I  know,  and  these 
were,  Delore's  case,  due  to  scarlatina,  and  Tillaux's,  caused 
by  pyaemia.  The  autopsy  in  Delore's  case  showed  changes 
like  those  which  had  been  observed  in  experiments  on  the 
cadaver. 

The  cracking  sounds  during  the  operation  were  due  to 
tearing  of  the  periosteum  of  the  lower  i  of  the  femur  by 
the  external  lateral  ligament ;  to  separation  of  the  epiphyses 
at  the  inner  condyle  of  the  femur,  and  of  the  external 
tuberosity  of  the  tibia,  and  of  the  head  of  the  fibula ;  to  the 
elasticity  of  the  femur  and  tibia,  and  to  gliding  of  the 
loosened  epiphysis  of  the  femur  and  tibia  up  and  inwards. 
The  articular  surfaces  were  not  in  contact  on  the  outer  side 
of  the  joint. 

Experiments  on  the  dead  bodies  of  children  from  fifteen 
months  to  two  years  old,  by  Samuel,  Barberin,  Barber  and 
others,  confirm  Delore's  observations.  In  seven  cases  the 
femoral  epiphysis  was  alone  separated,  and  twice  with  the 
tibial  epiphysis  ;  three  times  the  tibial  epiphysis  was  alone 
separated,  and  the  external  lateral  ligament  was  torn  in  three 
cases,  but  this  does  not  appear  to  be  the  case  in  the  living, 
for  the  periosteum  and  epiphysis  yield  in  preference  to  the 
ligaments.  In  the  cadaver  this  is  reversed,  for  in  Santi's 
twelve  experiments  the  external  lateral  ligament  was  ruptured 
nine  times,  twice  the  external  condyle  was  separated,  and 
was  once  fractured  into  the  joint. 

Though  in  several  there  was  no  noticeable  local  or  consti- 
tutional mischief,  still,  in  many  cases,  there  has  been  arthritis 
with  effusion  and  rise  of  temperature ;  and  the  separation  of 
the  periosteum  has  caused  severe  periostitis  and  superficial 

s 


258  BODILY    DEFORMITIES. 

necrosis,  more  than  once.  Tillaux  had  a  death  from  pyaemia 
after  the  operation.  It  is,  however,  right  to  state  that  these 
as  immediate  results  of  the  operation  are  exceptional,  and  if 
we  consider  the  age  of  the  patients  operated  on,  (this 
method  not  being  suitable  after  the  age  of  twelve,  though 
Delore  puts  the  limit  at  eighteen)  and  recollect  how  well 
children  bear  operations  as  a  rule,  we  should  not  expect 
them.  In  them  the  epiphysis  separates  much  more  readily 
than  the  ligaments  tear,  and  if  the  operation,  in  rachitic 


Fig.  116. — A  case  of  double  genu  valgum  in  a  boy  aged  7.  which  was  straightened 
by  Delore's  method. 

cases,  be  done  during  the  stage  of  softening,  the  compara- 
tively easy  separation  of  the  epiphysis  in  such  cases,  is  just 
that  which  allows  the  deformity  to  be  reduced. 

After  twelve  years  of  age,  and  after  the  period  of  sclero- 
sis in  rachitic  cases,  the  operation  is  not  advisable,  because 
then  the  ligaments,  and  especially  the  external  lateral,  are 
ruptured,  and  one  or  both  condyles  fractured,  and  the  least 
inconvenience  resulting  is  an  articular  looseness.  So  that 
this  operation,  which  may  be  called  7nanual  osteodasy,  is 


GENU    VALGUM    AND    OSTEOTOMY.  259 

anything  but  a  thoroughly  safe  one,  and  is  far  inferior  to 
osteotomy,  both  as  regards  safety  and  permanent  usefulness 
of  the  joint.  Moreover,  one  cannot  satisfactorily  tell  what 
has  occurred,  whether  an  epiphysis  has  separated,  which  is 
desirable,  or  whether  a  fracture  of  the  condyles,  a  rupture 
of  the  ligaments,  or  a  separation  of  the  periosteum  have 
occurred ;  or  whether,  as  has  happened,  the  femoral  shaft  has 
been  broken. 

The  remote  results  of  the  operation  are  a  weak  and  lax 
joint,  necessitating  long  rest  before  it  can  be  used  with  any 
safety,  and  then  the  frequent  necessity  of  a  retentive  appa- 
ratus, not  only  to  permit  of  safe  progression,  but  to 
prevent  relapse.  Delore  states  that  epiphysial  disjunction 
does  not  impede  the  development  of  the  bone,  and 
Barbarin  has  proved  that  in  fracture  of  the  lower  end  of  the 
femoral  shaft,  if  the  epiphysial  cartilage  remain  attached 
to  the  epiphysis,  proper  nutrition  will  be  provided  for. 
However,  as  there  may  be  risk  of  defective  growth  after 
the  injury,  I  think  all  will  agree  that  the  operation  should 
be  abandoned.  In  my  opinion  it  is  rough  and  unsurgical, 
and  I  shall  never  again  repeat  it.  I  expressed  this  opinion 
some  years  ago,  and  though  Fochier  defended  this  opera- 
tion at  the  London  International  Congress  of  1881,  not  a 
single  voice  was  raised  in  its  favour.  On  the  other  hand,  it 
must  be  mentioned  that  osteotomy  (and  the  antiseptic  method 
also)  has  been  very  slowly  received  in  France,  and  that 
Bceckel,  Beaurigard  and  Tillaux,  are  about  the  only  surgeons 
who  have  practised  it,  the  first  named  pretty  extensively, 
however.  Our  neighbours,  though  quick  by  nature,  are  very 
slow  to  accept  English  or  German  novelties ;  and  perhaps  wre 
should  not  blame  their  conservatism,  seeing  that  they  do 
not  very  readily  accept  the  new  devices  of  their  own 
confreres,  though  when  an  operation  is  established,  they  are 
quick  to  find  any  evidence  which  their  surgical  records  or 

s  2 


260  BODILY    DEFORMITIES. 

oral    tradition,  furnish    of   French    priority    of    discovery, 
suggestion,  or  practical  application. 

Forcible  instrumental  reduction.— A  few  words  con- 
cerning this  method,  for  the  sake  of  completeness.  One- 
great  objection  to  Delore's  method  is  the  great  amount  of 
force  sometimes  necessary,  and  the  difficulty  in  regulating  it. 
He  has  called  in  the  aid  of  eight  assistants,  in  some  cases, 
before  the  cracking  sound,  followed  by  reduction,  was 
obtained.  To  avoid  this,  and  at  the  same  time  be  able  to 
measure  the  amount  of  force  put  forth,  Colin,  a  Parisian 
instrument  maker,  constructed  an  apparatus  to  effect  the 
same  purpose.     I  need  not  describe  it. 

Osteotomy  and  Osteectomy.— Osteotomy  may  be 
linear ;  cuneiform,  rounded,  etc.*,  the  former  plan  only  deserves 
the  name  of  osteotomy,  for  the  latter  are  really  osteectomies 
as  a  portion  of  bone  is  removed.  Osteotomy  may  be  com- 
plete, as  when  the  whole  thickness  of  the  bone  is  cut 
through,  or  partialis  when  only  |  or  *-  of  it  are  severed, 
and  the  rest  broken.  This  is  the  usual  method  in  opera- 
tions for  genu-valgum,  varum,  and  in  curved  tibia  and 
fibula.  The  other  methods  of  osteotomy  have  been  used 
for  mal-union  of  fractures,  bony  anchylosis  of  hip,  knee, 
elbow,  &c,  and  will  be  found  described  in  the  chapter  on 
anchylosis.  The  illustrations  on  page  268  will  show  the  line 
of  the  incisions  in  the  bones.  Chronological  sequence  is 
sacrificed  to  correct  classification. 

There  are  thirteen  different  operative  plans  foi  genu- 
valgum  and  varum  which  may  be  thus  tabulated. 


( Condylotomy  with   saw   (linear,  com- 
plete) ...  ..  ...  ...  ...     Ogston 

Osteotomy  of     Condylotomy  with   chisel    (linear,   in- 
femur     ...  complete)      ...         ...         ...         ...     Reeves. 

Supra-condylar  (linear  internal,  incom- 
plete)...        ...        ...        ..         ...     McEwen. 


i.i  m     VALGUM     IND  OSTEOTOMY, 
Supracondylar  (linear  externa^  Incom* 


i6l 


Osteotomy  of  ( 
femui 


of  femur... 


plete)...  •■•  Reeve*. 

Diaphysial  (linear<\#ter»  //,  incomplete)  Reeves* 
l  piphy  iial    chrondrotomy    (may    be 

done) Oilier, 

,  Dicondyloid  (really  a  partial  excision)  Annandale. 

ff __       [  Cuneiform  of  internal  condyle  ...  Lniene. 

Mil   urn. 


..     Billroth, 
Meyer, 


Osteotomy  of     Uneai  ^complete)     ... 

tibia  ...  \ 
Osteectomy      |  Cuneiform         

of  tibia  ...  ' 
On  tibia  and   )  Osteectomy  (cuneiform)  of  tibia,  and 

fibula     ...   i     linear  complex  osteotomy  of  fibula  .    Schede, 

On         femur 
and  tibia... 


)  Linear  (incomp 


(incomplete) 


\'>.u  well, 


Osteotomy  is  an  old  operation,  for  Hippocrates  recom 
mends  it  for  badly  united  fractures,  and  it  was  practised  in 
thetirae  of  Paul  of  Egina.    Aibucasis,  a  little  later,  wrote  in 
favour  of  the  use  of  the  saw  in  preference  to  refracturing 
badly  united  bones.    Cucherilli*  says  he  also  recommended 

osteotomy  in  anchylosis  consecutive  to  juxta  ai til  ular  frac- 
tures.    Many  centuries  elapsed  before  the  question  was 

revived,  but  this  is  not  the  place  to  write  a  history  ot  OSteO 

tomy  in  general,  therefore  I  will  refer  those  interested  in 

this  matter  to  the  work  of  Mc.Kwen,  and  especially  of  Cam 

penon,  on  Osteotomy.  Some  historical  references  of  more 
recent  date  will  also  be  found  in  Dr.  Little's  recent  work  on 
Tn-kpee  distortion,     1  will  only  briefly  refer  to  the  history  of 

those  methods  which  have  application  to  orthopa-die   prac 

tice.   In  1570  Dechamps used  cutting  forceps  for  correcting 

a  badly  united  fracture.    In   1815  I  .cm.  inc.  excised  the  ends 

of  the  tibia  for  vicious  callus.     In  1816  Wasserfuhr  did  the 

first  linear   osteotomy  with  open  wound   for  a  badly  united 

•  M  Lo  Sperimentali,"  May,  iSyS. 


262  BODILY    DEFORMITIES. 

fracture  of  the  femur  in  a  child  ;  in  1826,  Riecke  and  Rhea 
Barton  performed  osteotomy  at  the  femoral  neck  and  tro- 
chanter for  anchylosed  hip  ;  and  in  1835,  he  did  cuneiform 
osteotomy  for  anchylosis  of  the  knee,  and  was  speedily 
followed  by  Kearney  Rodgers.  In  1834,  Clemot*  of  Roche- 
fort  instituted  cuneiform  excision  of  vicious  callus,  and  was 
followed,  probably  quite  independently,  by  Rhea  Barton. 
These  operations  were  all  by  open  wound,  and  the  saw  or  for- 
ceps, or  both,  were  used.  In  1840,  Jobert  de  Lamballe  per- 
formed the  first  osteotomy  for  rachitic  curvature,  and  in  1847, 
Maisonneuve  did  the  first  osteotomy  in  France  for  anchylosis 
of  the  hip.  In  1854,  subcutaneous  osteotomy  was  intro- 
duced, and  it  was  first  suggested  by  Malgaigne  in  his  work 
on  Fractures  and  Dislocations  in  1847  ;  so  that  the  honour  of 
the  idea  belongs  to  France,  though  two  German  surgeons, 
Meyer  and  ~Langenbeck,  jirst practised  it  for  mal-union  of 
fractures  and  rachitic  curves.  The  operation  was  done  in 
America  by  Brainard  (1854)  and  by  Pancoast  (1859),  and 
became  popular  for  a  time,  but  thereafter  was  only  occasion- 
ally practised,  being  in  this  respect  like  most  methods  of 
treatment,  fashionable  for  a  season,  until  the  mind  became 
satiated  with  the  new  surgical  toy.  In  1850  to  185 1,  Meyer 
of  Wiirzburg,  a  surgeon  paying  great  attention  to  ortho- 
paedics, performed  the  first  osteotomy  for  genu  valgum.  His 
patient  was  very  rachitic,  and  Meyer  had  in  mind  more  the 
correction  of  the  rachitic  curve  than  the  genu  valgum,  as 
he  operated  at  the  seat  of  greatest  curvature.  In  1852, 
Langenbeck  proposed  osteotomy  in  two  cases  of  anchylosed 
knee,  and  his  plan  was  to  perforate  the  bone  in  two  places 
with  a  drill,  and  to  pass  his  fine  saw  into  one  of  the  holes 
and  saw  through  the  intervening  part  of  bone,  then  to  break 
the  bone.  McEwen  is  incorrect  in  saying  that  Langen- 
beck did  these  operations,  for  he  only  proposed  them,  but 
*  "  Gazette  Medicale  de  Paris,"  1834,  p.  347. 


GENU    VALGUM    AND    OSTEOTOMY.  263 

the  patients  declined.  In  1859,  Pancoast  perforated  the 
femur  in  six  places  with  a  strong  gimlet,  through  a  single 
subcutaneous  opening,  just  above  the  knee  for  anchylosis,  and 
Brainard  repeated  the  operation  in  i860,  using  a  perforator. 
In  1862,  Sayre  operated  for  anchylosed  hip;  in  1868,  Stro- 
meyer  Little  operated  with  a  chisel  for  anchylosed  knee  ; 
Brodhurst  in  1865  performed  subcutaneous  osteotomy;  and 
in  1869  and  1871  Adams  did  subcutaneous  section  of  the 
femoral  neck  for  bony  anchylosis  of  the  hip,  and  was  soon 
followed  by  Gant,  Maunder,  and  bvrne^  It  was  not  till 
1875,  encouraged  by  the  antiseptic  method,  that  Annandale 
excised  a  portion  of  the  femoral  condyles  for  genu  valgum. 
His  operation  was  in  reality  a  partial  excision  of  the  joint, 
and  the  honour  of  introducing  a  method  which  was  the 
precursor  of  our  present  more  perfected  modes  of  dealing 
with  genu  valgum,  varum,  &c,  is  due  to  Ogston  junior,  of 
Aberdeen,  who  operated  in  May  1876,  by  a  small  wound  and 
using  a  saw,  and  was  followed  by  Schede  in  September  of  the 
same  year.  In  this  method  the  joint  was  opened  under  strict 
antiseptic  precautions  ;  but  antiseptic  osteotomy  was  intro- 
duced by  Volkmann  of  Halle  for  anchylosis  of  knee  in  1875, 
and  the  first  operation  of  this  kind  in  Great  Britain  was  by 
McEwen  of  Glasgow.  Billroth  introduced  the  use  of  the 
chisel  in  1870,  and  in  1873  did  non-antiseptic  linear  osteo- 
tomy of  the  tibia,  in  1872  for  genu  varum,  and  in  1873  for 
valgum.  Schede  of  Berlin  did  cuneiform  osteectomy  of  the 
tibia  and  osteotomy  of  fibula  for  knock-knee  in  1876.  In 
1877  Chiene  of  Edinburgh  did  cuneiform  osteectomy  of 
part  of  the  internal  condyle,  and  in  1878  McEwen  chiselled 
out  a  wedge  of  the  inner  condyle  along  Ogston's  line. 
Ogston's,  Chiene's,  and  McEwen's  cuneiform  operations  have 
been  termed  osteo-arthrotomy,  or  inter-articuta?'  osteotomy ; 
and  although  my  condylar  plan  has  been  included  under  this 
*   "Deutscheklinik,"  1854,  Vol.  6,  p.  327. 


264  BODILY    DEFORMITIES. 

head,  experience  has  shown  that  it  is  practically,  i  e.  as 
regards  its  effects  on  the  joint,  an  extra-articular  method. 
In  the  same  year  Barwell  performed  "  simultaneous  mul- 
tiple osteotomy"  for  knock-knee  ;  and  in  1879  I  introduced 
an  operation  in  which  I  used  the  chisel,  and  termed  it  extra- 
articular osteotomy  or  condylolomy,  the  object  of  which  was 
to  avoid  entering,  or  doing  serious  damage  to  the  joint,  and 
at  the  same  time,  to  loosen  and  properly  replace  the  dis- 
placed condyle.  That  the  operation  differed  essentially  in 
principle  from  Ogston's  operation,  and  that  its  immediate 
and  remote  results — though  most  of  my  cases  were  done  non- 
antiseptically — were  very  satisfactory,  is  not  only  testified 
by  my  cases  and  those  of  my  colleague  at  the  East  London 
Children's  Hospital,  Mr.  R.  Parker,  but  is  shown  by  the  fact 
that  Professor  Annandale  of  Edinburgh,  and  many  other 
British  and  foreign  surgeons,  freely  adopted  it,  and  were 
well  satisfied  with  its  results.  Mr.  Warrington  Haward,  in 
his  excellent  resume,  "  A  Treatise  on  Orthopaedic  Surgery, 
&c,"  gives  the  preference  to  this  operation,  and  Mr.  Barker 
of  University  College  Hospital,  and  many  other  surgeons, 
showed  their  appreciation  by  adopting  it.  All  other  opera- 
tions were  abandoned  by  unprejudiced  and  cautious 
surgeons  until  McEwen's  supra-condyloid  method,  first 
done  in  1877,  became  generally  known.  This  plan  has  been 
largely  used,  but  I  hear  from  many  quarters  that  it  is  being 
superseded  by  the  operation  which  I  first  did  and  described 
in  the  British  Medical  Journal  in  1881,  and  which  I  then 
called  mid-femoral  osteotomy,  but  a  better  name  is  diaphy- 
sial osteotomy.  The  object  of  this  operation  was  to  get 
well  away  from  the  joint,  to  have  a  much  smaller  section  of 
bone,  to  avoid  cancellous  tissue,-  to  have  less  secondary  or 
compensatory  deformity,  and  to  hide  this  under  the 
muscles ;  to  save  time  in  the  process  of  bony  union,  to  avoid 
inflammatory  effusion  into  the  joint,  and  injury  to  the  epi- 


GENU    VALGUM    AND    OSTEOTOMY. 


265 


physis,  and  also  to  prevent  haemorrhage,  and  splintering  of 
the  condyles  into  the  joint.  As  Campenon*  says,  there  have 
been  three  distinct  phases  in  the  choice  of  operative  pro- 
cedures. In  the  first,  with  Annandale  and  Ogston,  one 
boldly  opened  the  articulation.  In  the  second,  represented 
by  Reeves  and  by  Chiene,  one  endeavoured  to  respect  it. 
....  In  the  third,  one  leaves  the  joint  at  a  distance  and 
does  not  operate  in  its  neighbourhood,  like  Billroth  and 
McEwen;  but  rather  like  Reeves  (2nd 
method)  and  Taylor,  one  carries  the 
section  to  the  diaphysis."  The  early 
operations  were  conceived  under  the 
belief  that  the  internal  condyle  was 
elongated  and  was  the  chief,  if  not  the 
sole,  cause  of  the  deformity ;  but  the 
last  few  years  of  practical  experience 
have  proved  that  whatever  and  wherever 
the  pathological  changes  may  reside 
and  predominate,  in  those  cases  suit- 
able for  the  operation,  the  distortion 
can  be  effectively  and  permanently  cor- 
rected by  diaphysial  linear  osteotomy. 

J  •*■    "  Fig.  117. — Diagram     to 

I  need  not  occupy  space  by  describing  show  where   the  bone  is 
all  the  various  methods.     Those  inte-  divided  in  1.  internal  con- 

.  dylotomy;    2-    Diaphysial 

rested  will  find  them  well  summarized   osteotomy. 

in  Campenon's  work,  and  the  adjoining 

illustrations  will   convey  a  good  idea  of  the  nature  of  the 

different  operations.     It  will  suffice  to   describe  the  three 

plans  which  have  found  most  favour  and  yielded  the  best 

results,  viz.,  the  supra-condylar,  chisel-condylotomy,  and  the 

diaphysial. 

Supra- Condylar  Osteotomy    by   McEwen's  plan    is 
done  thus.     The  instruments  required  are  a  scalpel  (double 
*  "  Du  redressement  des  membres  par  l'Osteotomie,"  1883. 


s 


2  66  BODILY    DEFORMITIES. 

edged,  I  prefer),  a  chisel  or  osteotome,  which  should  be 
graduated  into  inches  and  parts  of  an  inch,  and  a  mallet  made 
of  lignum  vitae,  boxwood,  or  steel.  I  prefer  the  former,  and 
have  often  used  an  ordinary  mallet.  The  markings  of  the 
chisel  are  serviceable  in  measuring  beforehand  the  depth  it 
is  desired  that  it  should  penetrate  the  bone,  which,  being  re- 
membered, will  tell  us  when  attempts  may  be  made  to  break 
the  bone.  A  sand-bag,  or  thick  wooden  or  leaden  rounded, 
or  oblong  block,  well  covered  with  a  folded  towel,  to  place 
on  the  opposite  side  of  the  limb  to  be  operated  on,  and 
kept  in  place  by  an  assistant,  is  advantageous.  The  sand- 
bag, if  sufficiently  large,  needs  no  assistant.  McEwen  uses 
Esmarch's  bandage.  I  have  never  used  it,  and  see  no  neces- 
sity nor  advantage  in  it,  but  rather  the  reverse,  as  haemorrhage 
is  apt  to  follow  its  use,  and  has  pretty  often  occurred  in  this 
operation.  I  have  seen  troublesome  haemorrhage  at  the 
time  of  operation  by  the  internal  plan  without  the  use  of  the 
elastic  bandage,  and  have  recently  heard  of  a  case  in  which 
the  bleeding  point  had  to  be  sought  for,  and  joint  mischief, 
followed  by  serious  results  to  the  limb  (I  am  not  sure  as  to 
the  life)  of  the  patient,  necessitating  excision  or  amputation, 
was  the  consequence.  Splints,  or  Paris  plaister  bandages, 
should  be  ready  at  hand..  The  patient  being  anaesthetised, 
Esmarch's  bandage  is  applied,  and  a  large  bag  containing 
damp  sand  is  placed  beneath,  or  on  one  side  of,  the  limb  to 
be  operated  on,  to  resist  the  blows  of  the  mallet.  A  clean 
incision,  rather  larger  than  necessary  to  admit  the  largest 
osteotome,  is  made  at  once  down  to  the  bone  on  its  inner 
side,  about  an  inch  above  the  condyles.  Keeping  the  scalpel 
in  position,  it  serves  as  a  guide  on  which  to  introduce  the 
osteotome,  which,  on  reaching  the  bone,  is  turned  at  right 
angles  to  it,  and  the  mallet  applied.  The  strength  of  the 
blows  will  vary  with  the  hardness  of  the  bone,  and  can  only 
be  acquired  after  experience,  some  bones,  even  of  young  chil- 


GENU    VALGUM    AND    OSTEOTOMY. 


267 


dren,  being  very  dense,  while  others  are  easily  severed.  The 
bone  being  about  three  parts  cut  through,  is  then  broken 
from  the  i?iner  side,  either  forcibly,  or  better,  by  several  suc- 
cessive sharp  jerks  against  the  surgeon's  knee,  his  hands 
grasping  and  steadying  the  femur  while  he  uses  the  tibia  as  a 
lever.  The  limb  is  then  straightened,  the  wound  stitched  up 
or  covered  with  antiseptic  dressings,  if  the  operation  be  done 
antiseptically,  and  put  in  splints  or  plaister  of 
Paris.  McEwen  uses  a  special  splint,  and 
during  the  operation  advises  the  use  of  chisels 
diminishing  in  size.  I  think  this  a  bad  plan, 
for  the  soft  parts  are  apt  to  receive  additional 
injury  and  increase  the  tendency  to  suppuration. 
The  after-treatment,  according  to  McEwen, 
consists  in  being  watchful  that  the  circulation  in 
the  feet  is  right,  to  take  the  temperature  regu- 
larly, to  look  out  for  blood-stains  on  the  dress- 
ings, and  if  there  be  any,  to  change  them, 
otherwise  they  may  be  left  for  a  fortnight  and 
then  changed.  In  from  a  month  to  six  weeks 
the  bone  is  consolidated,  and  the  patient  is 
allowed  to  flex  the  knees,  assisted,  if  necessary, 
by  passive  motions.  Walking  on  crutches  is 
then  permitted,  and  in  ten  weeks  after  removal 
of  the  splints  the  patients  have  firmly  united 
limbs  and  may  walk  with  supports. 

I  have  followed  McEwen's  directions,  as  regards  site  of 
operation,  in  three  cases,  but  have  in  several  operated  from 
the  outer  side,  and  was  the  first  to  introduce  this  modi- 
fication, which  for  several  reasons  I  consider  preferable. 
McEwen's  preference  for  the  internal  method  has  reference 
to  certain  mechanical  views.  His  reasons  {op.  tit.  pp.  144-7) 
axe,  first,  that  the  section  of  the  femur  at  this  point  is  conical, 
the  base  being  external,  so  that  by  the  internal  method  the 


268 


BODILY    DEFORMITIES. 


surgeon  cuts  towards  the  base  from  the  apex,  and  that  in  it, 
the  chisel  is  not  apt  to  slip  and  wound  the  soft  parts  and 
the  femoral  artery.  There  is  confusion  in  this  paragraph,  for 
he  first  states  that  a  disadvantage  of  the  external  incision  is 
that  the  surgeon  cuts  towards  the  base,  and  lower  down  he 
says  that,  in  the  internal  plan,  "  one  cuts  from  an  apex 
towards  an  osseous  base,"  &c.     That  these  objections  are 


y*JC 


Figs.  119  and  120. — Diagrams  to  show  the  lines  of  bony  section  in  the  various 
operations  for  genu  valgum.  1.  Annandale's  ;  2.  Ogston's  ;  3.  Points  to  where  my 
incision  ceases  ;  4  and  7.  Barwell's  plan  on  both  bones  ;  5.  Shows  the  wedge  of  tibia 
removed  by  Meyer  and  adopted  by  Schede  with  section  6  of  fibula  ;  7.  McEwen's  ; 
8.  McEwen's  cuneiform  ;  9.  Chiene's  cuneiform ;  10.  On  femur,  McEwen's  supra- 
condylar; 10.  On  tibia,  Barwell's  tibial  section  ;  11.   My  diaphysial  operation. 


fanciful  ample  experience  has  proven,  and  that  the  section 
of  the  bone  at  this  spot  is  not  conical  in  the  sense  of  base 
and  apex,  but  rather  resembles  a  basic  section  of  an  ir- 
regularly-shaped cone,  figure  22  at  p.  121  of  McEwen's 
book  sufficiently  shows.  Secondly,  that  the  wedge-shaped 
opening  on  the  outer  side  further  shortens  the  already 
shorter  side  of  the  limb.  This  I  fail  to  see,  though  of  course  in 
straightening  the  leg  a  large  gap  will  be  left,  but  when  filled 


GENU    VALGUM    AND    OSTEOTOMY.  269 

up,  as  in  my  experience  it  invariably  does,  and  that  in  the 
same  space  of  time   as   in  the  internal   method,  the  outer 
and  shorter  side   of   the  leg  will  be  properly  lengthened. 
Moreover,  that  McEwen's  statements  and  illustrations  were 
published  under  an  incorrect  conception  of  the  mode   in 
which  correction  of  the  deformity  is  obtained  will  be  obvi- 
ous to  all,  if   the   following  simple  experiment   be  made. 
Draw  the  lower  end   of   a  femur  and  place  the  tibia  in 
juxtaposition,  at  the  angle  it    has  in  an  average  case  of 
genu   valgum.     Cut  through    the    condyles  at  the  line  of 
McEwen's  incision,  and  replace  the  parts,  then  it  will  be 
seen  that  it  matters   not  on  which  side  the  incision  has 
been  made,  for  on  bringing  the  tibia  into  a  right  line  with 
the  median  body-plane,  a  large  gap   on  the  outer  side  does 
and  must  occur,  in  any  case.     It  is  often  impossible,  with- 
out further  operative  procedures,  such  as  tenotomy  of  the 
biceps,  &c,  to  properly  correct  the  deformity  without  it. 
Thirdly,  the    supposed    ill    effects    of   stretched  or  torn 
periosteum  I  have  never  witnessed,  though  a  large  and,  for 
some  time,  ugly  mass  of  callus  has  appeared  at  the  seat  of 
operation   in    the    external,  as    in    the    internal  methods. 
Fourthly,  he  says,  "  that  though  suppuration  would  rarely 
take  place,  still,  if  it  did  so,  it  would  not  readily  find  vent, 
owing  to  the  manner  in  which  the  tissues  on  the  outside  of 
the  thigh  are  bound  down  by  the  fascia  latea  "  ;  and  he  men- 
tions two  cases  of  the  external  operation  by  other  surgeons, 
in  which  suppuration  occurred   (in   spite  of  Listerian  pre- 
cautions, I  take  it,  as  in  many   other  cases  I  know  of)  and 
counter-openings  had  to   be  made.     All  I  can  say  in  reply 
to  this  (and  taking  into  consideration  many  other  cases  of 
antiseptic  linear  osteotomy,  including  some  of  McEwen's 
own  cases),  is,  that  in  an  experience  of  osteotomy  second 
only  to  McEwen,  in  which,  in  only  six  cases  were  antiseptic 
precautions  adopted,  and  that  of  all  my  cases  only  six  sup- 


270  BODILY    DEFORMITIES. 

purated,  and  two  of  these  were  supposed  antiseptic  cases, 
that  all  had  perfect  limbs,  and  none  died.  Four  of  the  cases 
that  suppurated  broke  out  in  scarlatina  or  measles  from  a 
few  hours  to  three  or  four  days  after  operation,  and  were 
instances  of  the  so-called  traumatic  form  of  these  diseases. 
Some  remark  is  needed  with  reference  to  McEwen's  fifth 
objection  "  that  the  production  of  straight  useful  limbs  by  the 
external  plan  is  no  sufficient  reason  for  preferring  that  plan." 
He  satirically  illustrates  his  meaning  by  mentioning  cases  of 
fractures  of  the  thigh  in  genu-valgoid  patients,  after  severe 
accidents,  being  rectified  by  being  put  up  in  a  straight 
position,  and  asks  if  one  would  adopt  that  method.  My 
reply  is,  "  Certainly,  we  do  imitate  the  plan,  but  we  adopt 
surgical  instead  of  blind  force."  I,  in  my  time,  like  most 
surgeons  with  large  surgical  opportunities  at  a  hospital  like 
the  London,  which  is  the  hospital  par  excellence  for  acci- 
dental surgery,  have  corrected  knock-knee  and  bow-legs  in 
patients  admitted  with  fractured  thighs,  by  using  extension 
and  long  straight  splints  ;  and  the  only  wonder  to  me  is  that 
none  of  us  thought  sooner  of  making  use  of  this  valuable 
lesson.  That  excellent  correction  and  perfectly  useful  limbs 
result  from  the  external  incision  there  can  be  no  question,  and 
that  it  is  anatomically  and  surgically  preferable  to  McEwen's 
plan,  ought  to  go  almost  without  saying.  There  is  no  fear 
of  bleeding,  the  side  which  it  is  desired  to  lengthen  is 
attacked,  and  as  the  bone  may  be  broken  from  the  inside  the 
chisel  can  be  kept  in  place  while  this  is  being  attempted, 
which  would  be  awkward  according  to  McEwen's  plan  ;  but 
in  it,  the  bone  could  be  broken  from  the  outside,  though 
this  would  militate  against  his  mechanical  theory.  He  says 
that  the  outer  side  is  the  shorter.  Is  this  so  to  any  great 
extent  ?  If  a  tense  tape  be  put  from  the  anterior  superior 
spine  or  great  trochanter  to  the  external  malleolus  the 
limb  will  be  found  shorter,  but  if  the  bones  themselves  be 


GENU    VALGUM    AND    OSTEOTOMY.  27 1 

measured  the  result  will  be  very  different,  and  this  is  why 
on  correcting  the  deformity  we  do  not  get  the  amount  of 
lengthening  we  might,  on  superficial  consideration,  expect. 
If  the  supra-condylar  operation  be  adopted  the  external 
incision  is  preferable,  for  the  reasons  above  given,  but  there 
are  other  serious  objections  to  the  supra-condylar  method 
which  must  be  stated.    It  is  too  near  the  joint,  and  effusion 
is  apt  to    occur  through   laceration   of  the  supra-patellar 
pouch   of   synovial    membrane,  or    through    inflammation 
extending  to   it  and  the  joint  cavity.     There  is  an  ugly 
hunk  of  callus  for  some  time  at  the  site  of  operation.    More 
or  less  stiffness  of  the  joint  has  resulted  as  a  consequence 
of  this  operation.     Serious  and  nearly  fatal  bleeding,  neces- 
sitating  further   operative    measures,   have    occurred,   and 
splintering  of  the  condyles  into  the  joint,  as  recorded  by 
Little,  Rabagliati  {Brit.  Med.  Journal,  1883),  and  others. 
Langton  of  St.   Bartholomew's,  McGill  of  the  Leeds  Infir- 
mary, and  Jackson  of  the  Sheffield  General  Infirmary  have 
recorded — the  two  former  in  the  Lancet  and  the  last  in  the 
Medical  Press  and  Circular,  July  9,  1884 — serious  mishaps, 
and  even  death,  due  to  this  operation.     Mr.  Jackson  says, 
in  speaking  of  McEwen's  operation,   "  But  are  there  no 
accidents,  sometimes  leading  to  death,  of  which  we  hear 
nothing  ?    Mr.  Langton  of  St.  Bartholomew  has,  all  honour 
to  him,  published  one.     I  know  of  others  ;  and  it  is  highly 
probable  that  the    popliteal  has  been  wounded   both    in 
Ogston's  and  McEwen's  operation  on  the   femur."      He 
proceeds  to  mention  a  case  of  Ogston's  operation,  done 
with  the  strictest  Listerian  precautions,  getting  pyaemia  and 
empyema.     But  now,  the  diaphysial  operation  has  been  for 
some  time  in  our  hands,  and  as  it  fulfils  every  indication  for 
the  correction  of  the  large  majority  of  cases  of  these  defor- 
mities, and  is  free  from  the  risks  of  the  other  methods,  no 
surgeon  need  hesitate  as  to  its  choice. 


272  BODILY    DEFORMITIES. 

Internal  Condylotomy.— This  operation  was  first 
described  by  me  in  the  Brit.  Med.  Journal,  1876.  Its 
object  was  to  loosen  the  elongated  or  displaced  internal 
condyle  and  to  push  it  up,  and  thus  to  restore  the  normal 
position  of  the  joint.  The  patient  being  anaesthetised,  the 
knee  is  flexed  to  a  right  angle  to  render  the  condyles  pro- 
minent, so  that  the  length  of  the  inner  one  may  be  taken 
from  the  point  of  entry  of  the  chisel  to  about  a  quarter  of 
an  inch  from  the  articular  cartilage,  and  also  to  pull  the 
sub-crural  pouch  of  synovial  membrane  out  of  the  way 
as  much  as  possible.  A  scalpel,  dipped  in  oil  either  medi- 
cated with  carbolic  acid  or  thymol  or  plain,  is  passed 
obliquely  above  the  internal  tuberosity  down  to  the  bone. 
I  used  to  pull  the  skin  up  or  down  before  making  the 
incision,  but  this  is  not  needed,  the  operation  being  done 
with  the  knee  flexed,  so  that  when  straightened  the  incision 
does  not  coincide  with  the  wound  of  the  bone.  The 
chisel,  previously  dipped  in  the  oil,  is  passed  beside  the 
scalpel,  and  the  latter  is  first  malleted  into  the  condyle 
obliquely  inwards,  care  being  taken  to  notice  the  distance 
it  should  penetrate,  which  should  be  previously  inked  or 
chalked  on  it ;  but  now  the  exact  measurement  can  be 
recorded  on  the  graduated  osteotome.*  I  used  to  measure 
by  placing  the  chisel  on  the  front  of  the  condyle,  allowing 
for  the  depth  of  the  soft  parts  at  the  tuberosity.  The 
chisel  should  then  be  carefully  and  partially  withdrawn 
with  a  lateral  motion,  and  its  axis  changed  anteriorly  and 
posteriorly  so  as  still  further  to  loosen  the  condyle ;  and 
then,  if  necessary,  it  may  be  gently  used  as  a  lever  to 
further  loosen  it,  and  when  it  is  felt  to  be  sufficiently 
loose,  the  leg  is  to  be  grasped  and  drawn  firmly  and 
steadily  inwards,  when  a  soft  cracking  noise  will  be  heard, 

*  I  believe  Mr.  Parker,  my  colleague  at  the  East  London  Children's 
Hospital,  first  suggested  this. 


GENU    VALGUM    AND    OSTEOTOMY.  273 

and  the  leg  will  come  straight.  In  severe  cases  I  used  to 
over-correct  the  deformity  and  put  the  leg  up  in  very  slight 
varum,  but  this  is  not  necessary.  A  pad  of  oiled  lint  is 
placed  over  the  wound  (which  may  be  stitched  if  desired), 
a  thin  layer  of  cotton  surrounds  the  leg  and  thigh,  this  is 
covered  by  a  thin  flannel  bandage,  and  then  plaister  of 
Paris  rollers  are  applied.  An  ice-bag  was  often  applied 
over  the  knee  for  several  days  after  the  operation.  Neither 
spray  nor  antiseptic  dressings  were  used,  and  it  was 
extremely  rare  to  get  any  rise  of  temperature  or  local 
mischief,  though  sometimes  temporary  effusion  occurred. 
The  wound  was  not  looked  at  till  the  bandage  was  removed, 
which,  in  my  early  operations,  was  in  about  three  or  four 
weeks,  but  later  on  I  had  the  bandage  removed  in  ten  to 
fourteen  days — not  to  look  at  the  wound,  for  experience 
had  taught  me  not  to  trouble  about  that — but  to  allow  of 
gentle  passive  motion,  and  it  was  found  that  the  patients 
could  flex  their  knees  to  a  considerable  extent.  The  splint 
was  re-applied  and  removed  every  day  for  gentle  active 
and  passive  motion,  and  in  three  or  four  weeks  the  patients 
could  stand  and  walk,  though  it  is  not  advisable  to  allow 
this  for  some  two  or  three  weeks  longer.  This  operation 
led  me  to  introduce  two  important  innovations  into  surgical 
practice,  viz.  (1)  to  leave  the  wound  alone  unless  there 
were  distinct  indications  to  interfere  with  it,  and  (2)  to 
commence  passive  motion  early,  and  these  methods  have 
since  been  largely  adopted  by  surgeons. 

There  are  certain  objections  to  this  plan  which  are  to 
some  extent  valid,  but  at  the  time  the  operation  was  intro- 
duced it  was  acknowledged  to  be  a  great  advance  on  its 
predecessors,  and  in  practice  proved  to  be  so.  The 
theoretical  objection  about  the  joint  being  of  necessity 
opened  has,  I  am  happy  to  say,  never  been  proved  by 
cases  operated  on,  though  post-mortem  experiments   show 

T 


274 


BODILY    DEFORMITIES. 


that  this  is  apt  to  occur.  The  only  clinical  evidence  of 
this  is  furnished  by  those  few  cases  in  which  there  has  been 
effusion,  and  even  this  may  have  been  due  to  the  force 
used  in    straightening  the   limb.     In    some   cases   it    was 


Figs.  121  and  122. — Extreme  genu  valgum  in  a  young  man  of  seventeen  before 
and  after  condylotomy,  according  to  my  plan.  The  case  was  sent  me  by  Mr.  Morris, 
of  Tottenham,  the  cast  is  at  the  London  Hospital,  and  the  photographs  were  shown 
at  the  Clinical  Society  and  acknowledged  to  be  the  worst  case  seen  by  those  present, 
my  colleague,  Mr.  Brodhurst,  among  the  number. 


necessary  to  divide  the  biceps  tendon,  as  done  in  some 
instances  of  Ogston's  operation,  before  entire  rectification 
occurred.  Granting,  for  the  sake  of  argument,  that  the 
joint  is  always  opened  in  these  cases,  experience  has 
abundantly  shown  that  practically,  it  matters  not,  and  in  this 


GENU    VALGUM    AND    OSTEOTOMY.  275 

sense    the    operation   is    properly    called    extraarticular. 
Tearing  of  the    outer  structures,   as    in  Delore's  method, 
should  not,  as  a  rule,   occur  if  the  operation  have  been 
properly  done,   and  especially  if  the  biceps  be  divided  in 
case  of  difficulty.     Stiffness  of  the  joint  has  occurred,  but 
only  temporarily.     Relapses  are  unknown  to  me  up  to  the 
present  date,   as  also  are    defective  development  of   the 
inner  side  of  the  femur,  or  epiphysial  necrosis  ;  but  there 
are  two  cases  to  which  I  will  draw  attention  as  furnishing 
valuable  lessons.   In  a  lad  aged  seventeen,  with  extreme  genu 
valgum  (see  Fig.  121)— the  cast  and  photographs  of  which, 
when  shown  at  the  Clinical  Society,  were  acknowledged  by 
experienced  surgeons  to  be  the  worst  they  had  seen— whose 
internal  condyle  was    extremely    elongated    and   flattened 
from  before  backwards,  so  as  to  be  less  than  half  its  natural 
thickness  at  its  upper  part,  and  the  lower  quarter  of  whose 
femur    was    much    curved   inwards,    the    condyle  became 
comminuted,  and  there  was  extensive  bleeding,  so  that  the 
joint  filled  twice,  and  I  pressed  the  blood  out  of  it  and  kept 
up  pressure  while  the  limb  was  being  straightened.     I  did 
not  put  my  finger  into  the  wound,  but  the  broken  bones 
could  be  felt  to  be  like  a  bag  of   large  marbles,  and  the 
blood  came  pretty  freely  through  the  wound.     Here  was 
a  compound  comminuted  fracture  into  the  largest  joint  in 
the  body,  complicated  with  haemorrhage.    I  put  a  pad  of  lint 
over  the  wound  and  plaister  of  Paris  bandage  in  the  ordinary 
way.     At  eleven  at  night,  the  house   surgeon,   Sir  Andrew 
Clark's  son,  sent  for  me  because  bleeding  had  stained  the 
plaister  and  oozed  up  the  thigh  and  down  the  leg.     The 
lad  was  flushed,  had  a  rapid  pulse,  and  temperature  of  nearly 
10 1  °.     My  first  idea  was  to  remove  the  bandage  and  to  see 
if  I  could  check  the  bleeding,  but  I  decided  to  continue  with 
the  ice-bag  and  to  push  morphia  to  ease  the  pain.     I  left 
instruction  that  if  no   improvement   occurred  I  was  to  be 

t  2 


276  BODILY    DEFORMITIES. 

summoned.  I  heard  no  more  from  the  house  surgeon,  and 
at  my  next  visit,  temperature,  pulse,  &c,  were  normal,  and 
the  bleeding  had  not  recurred.  In  four  weeks  from  the 
date  of  operation  the  plaister  was  removed,  and  the  lad 
could  voluntarily  flex  his  knee  to  a  considerable  extent, 
and  in  another  fortnight  left  the  hospital  with  a  straight 
limb,  lengthened  nearly  three  inches,  and  with  perfect 
motion,  though  with  a  broadened  joint.  In  this  case 
the  joint  was  considerably  broadened  by  the  deformity. 
This  lad  was  from  a  suburban  workhouse,  and  I  cannot 
but  think  that  if  I  had  disturbed  his  bandages  to  examine 
the  wound,  the  result  would  have  been  most  serious. 
Had  this  case  occurred  to  a  Listerite  it  would  undoubtedly 
have  been  claimed  as  a  great  antiseptic  success.  I  do  not 
quote  it  as  an  example  to  be  followed  either  antiseptically 
or  aseptically,  i.e.,  with  cleanliness  without  antiseptic  dress- 
ings and  the  spray,  but  merely  to  show  what  nature  can 
do,  even  in  a  badly  fed  workhouse  lad,  when  left  to  herself, 
and  without  meddlesome  surgery.  As  to  where  the  bleed- 
ing came  from  I  did  not  know,  but  feared  that  a  spiculum 
of  the  comminuted  bone  had  punctured  the  popliteal  artery 
or  vein  or  the  superior  internal  articular.  The  result  would 
tend  to  contradict  this  view,  but  wounds  of  large  vessels 
are  sometimes  recovered  from  if  a  fair  chance  be  given 
them. 

The  second  case  conveys  a  different  lesson.  It  was  one 
of  double  genu  valgum.  I  loosened  both  internal  condyles 
at  one  sitting  and  put  them  up  slightly  over-corrected. 
This  case  was  brought  to  me  about  three  months  ago, 
among  the  out-patients  of  the  London  Hospital,  five 
years  after  the  operation,  and  there  was  noticeable,  though 
not  severe,  genu  extrorsum.  This  was  due  to  free  growth 
of  the  previously  smaller  external  condyles.  The  inner 
condyles  were   smaller  than  the  outer,  and  the  extrorsum 


GENU    VALGUM    AND    OSTEOTOMY. 


77 


was  probably  due,  either  to  excessive  growth  of  the  outer 
condyles  subsequent  to  the  operation,  which  relieved  them 
of  undue  pressure,  or  to  defective  growth  of  the  inner ; 
and  this  may  have  been  a  result  of  the  operation  having 
interfered  with  the  inner  part  of  the  epiphysial  cartilage. 
The  over-correction  of  the  deformity  may  have  aided  in 
this  direction. 


Figs.  123  and  124.  -Severe  genu  valgum  and  slight  secondary  varum  in  a  girl  aged 
sixteen,  before  and  after  internal  condylotomy. 


Here  I  may  mention  another  complication  which  may 
occur  when  passive  motion  is  resorted  to  in  a  case  of 
osteotomy.  It  occurred  recently  at  the  London  Hospital, 
in  a  girl  aged  thirteen.  The  dresser,  one  day,  on  using 
passive  motion,  about  a  week  after  it  had  been  commenced, 
felt  something  crack,  and  I  found  on  examination  that  the 
upper  epiphysis   of  the   tibia  had  partly  separated.     Both 


278  BODILY    DEFORMITIES. 

femora  had  been  divided  in  their  shafts,  the  right  about  a 
month  before  the  left,  and  that  gave  no  trouble.  The  tibia 
became  firm  in  three  weeks,  but  the  whole  left  limb 
behaved  very  differently  to  the  right,  and  in  a  manner  I 
have  not  before  met  with,  there  being  temporary  oedema  of 
the  left  thigh,  and  on  this  side  it  was  that  the  tibia  became 
fractured.  In  a  case  of  sub-trochanteric  osteotomy  for 
bony  anchylosis  of  right  hip  in  a  man  aged  fifty-four,  the  leg 
became  cedematous  when  he  was  allowed  up,  and  this  con- 
dition is  one  which  not  very  uncommonly  happens  after 
simple  fractures  of  the  lower  limb. 

Diaphysial  Osteotomy. — This  operation  was  described 
by  me  in  the  Brit  Med.  Journal,  1881,  and  since  then  I 
have  almost  invariably  adopted  it,  and  have  by  it  been  able 
to  correct  severe  deformities.  It  consists  in  dividing  the 
femur  from  the  outer  side  at  the  junction  of  its  middle 
and  lower  thirds.  I  do  not  use  Esmarch's  bandage  in  this 
operation,  nor  the  spray,  nor  antiseptic  dressings,  and  I 
make  it  a  point  not  to  change  chisels  unless  one  become 
blunt.  I  am  sure  that  in  the  six  or  seven  cases  in  which 
temporary  suppuration  occurred,  it  was  caused  by  having 
to  change  chisels,  and  the  difficulty  in  so  doing  of 
accurately  finding  the  opening  in  the  bone  without  doing 
damage  to  the  soft  parts.  I  have  already  given  my  reasons 
for  preferring  it,  and  need  only  say  that  the  after-treatment 
consists  in  leaving  well  alone,  and  not  removing  the 
plaister  until  the  bone  is  consolidated,  which  is  usually 
in  four  or  five  weeks.  Passive  motion  of  the  knee  is  then 
resorted  to,  and  the  patient  allowed  to  walk  on  crutches  for 
a  short  time  longer,  and  then  discharged  cured.  If,  in 
correcting  the  deformity,  the  leg  is  not  as  long  as  its  fellow, 
extension  with  a  stirrup  should  be  applied,  taking  the  fixed 
point  for  the  strapping  along  the  lower  fragment.  This 
should  only  be  moderate,  as  in  the  event  of  there   being 


GENU    VALGUM    AND    OSTEOTOMY.  279 

sufficient  reparative  power,  the  greater  the  gap  between  the 
bones,  the  longer  will  be  the  healing  process.  The  limb 
should  be  kept  in  the  corrected  position  and  well  extended 
till  the  plaister  sets,  or  a  long  and  broad  straight  splint,  well 
padded  over  the  trochanter,  internal  condyle,  and  malleoli, 
should beapplied  on  the  outer  or  inner  side,till  it  sets.  I  prefer 
the  inner,  because  in  bandaging  the  limb  to  the  splint  when 
on  the  outer  side,  the  loose  ligaments  of  rickety,  i.e.,  the 
commonest  cases,  stretch  and  allow  of  some  correction  of 
the  deformity,  which  disappears  afterwards,  and  this  may  lead 
to  some  disappointment  in  the  result,  whereas  I  have  not 
found  this  to  be  the  case  when  it  is  applied  on  the  inner 
side.  If  the  opposite  limb  be  straight  it  may  be  used  as 
a  splint,  and  the  internal  condyle  and  malleolus  being  well 
padded,  the  knees  and  ankles  are  made  to  touch  and 
bandaged  together  until  the  plaister  is  quite  firm.  I  may 
now  state  that  I  have  never  met  with  non-union  either  in 
the  femur  or  tibia,  though  such  an  event  may  occur ;  but  as 
it  has  almost  never  happened  in  the  practice  of  those  of  large 
experience  in  osteotomy,  it  may  be  that  this  result  is  due  to 
inexperience,  or  to  some  constitutional  or  local  fault  in 
the  patient,  or  to  a  piece  of  muscle  having  got  between 
the  fragments. 

Osteeetomy  or  Cuneiform  Osteotomy  consists  in 
removing  a  wedge-shaped  piece  of  bone  from  the  shaft  or 
condyles  of  the  femora,  or  from  the  tibial  shaft.  This 
operation  is  not  necessary  in  genu  valgum  or  varum  or  in 
bowed  tibiae,  and  is  not  now  practised. 

The  following  account  of  osteotomies  for  various 
deformities  done  by  me  during  the  last  ten  years  renders 
a  full  and  accurate  account  of  all  hospital  cases,  and 
includes  three  private  ones.  These  are  the  only  cases  I 
have  done  out  of  hospital.     Severe  deformity  is  rarer  in 


28o 


BODILY    DEFORMITIES. 


the  well-to-do  classes,  as  cases  are  treated  in   their  early 
stages  and  bone  operations  are  usually  declined.* 


Table  of  Osteotomies. 

I  must  mention  that  there  have  been  no  deaths,  no  joint 
suppuration,  nor  anchylosis.  All  the  cases  made  good 
recoveries  with  good  position  and  motion.  In  many 
instances  an  addition  of  one,  two,  or  more  inches  were  added 
either  on  one  side  or  on  both,  as  circumstances  dictated. 
I  have  always  used  the  chisel  and  never  removed  any 
bone.  Several  of  the  cases  were  simultaneous  double 
osteotomies  of  either  the  thigh  or  leg  bones.  I  only  used 
Listerian  precautions  in  six  or  seven  cases,  and  these  were 
not  vigorously  carried  out ;  and  when  I  add  that  suppuration 
only  occurred  in  six  cases,  and  that  two  of  these  were 
attempted  to  be  done  antiseptically,  and  that  in  four  of 
them  the  traumatic  form  of  measles  or  scarlatina  supervened, 
I  need  say  no  more  in  addition  to  that  I  have  previously 
stated  to  prove  the  perfect  safety  of  the  operation  in 
experienced  hands. 

I  had  thought,  knowing  how  soon  with  large  opportunities 
cases  mount  up,  that  the  number  of  my  osteotomies  would 
have  been  greater,  but  in  this  I  find  myself  mistaken. 

For  Deformities  of  Lower  Limb. 

CONDYLOTOMIES. 

12  for  genu  valgum,  10  double  and  2  single        =     22 
5  for  genu  varum,  4  double  and  1  single  =       9 

31  condylotomies. 

*  Since  the  above  was  written  I  have  operated  on  seventeen  other 
cases  for  deformities  of  the  lower  limb,  and  all  did  as  well  as  I  could 
wish. 


GENU  VALGUM  AND  OSTEOTOMY.  28 1 


Osteotomies. 


yy  for  genu  valgum,  63  double  and  14  single  =  140 

27  for  genu  varum,  20  double  and  7  single  =  47 

93  for  bowed  legs,  65  double  and  28  single  =158 

17  for  anchylosis  of  hip,  2  double  and  15  single  =  19 

7  for  anchylosis  of  knee,  all  single  ...          ...  =  7 

3  for  mal union  of  femur        ...          ...          ...  =  3 

2  for  malunion  of  leg  bones  (both  bones)  ...  =  4 


478  osteotomies  on 
lower  limb. 


For  Deformities  of  Upper  Limb. 

For  anchylosis  of  elbow        ...  ...  ...  ...  4 

For  anchylosis  of  shoulders  ...  ...  ...  ...  2 

For  malunion  of  humerus     ...  ...  ...  ...  2 

For  rachitic  curvature  of  humerus  ...  ...  ...  1 

For  rachitic  curvature  of  radius  and  ulna  (2  cases), 

3  osteotomies ...  ...  ...  ...  ...  3 

For  rachitic  curvature  of  radius  and  ulna  ...         ...  3 


15 

plus  478 


493  osteotomies   in 
all. 

Epiphysial  Chondrotomy.— Oilier  of  Lyons  intro- 
duced this  plan.  It  is  based  on  the  results  of  his  experi- 
ments on  the  epiphyses  of  long  bones.*  He  found  that 
one  can  alter  the  growth,  form,  and  direction  of  bones  by 
excising  the  whole  or  part  of  the  epiphysial  cartilages, 
and  he  put  the  results  of  his  experience  into  practice  on 
the  human  subject  with  success.  His  operation  was  on  the 
bones  of  the  forearm  and  leg,  in  cases  of  inflammatory 
lengthening  of  one  bone,  or  arrested  development  of  one 

*  De  l'excision  des  cartilages  de  conjugaison  pour  arreter  l'accroisse- 
ment  des  os  et  remedier  a  certaines  difformites  du  squelette. — Revue 
Mensuelle  de  Med.  et  de  Chirurgie,  1877. 


282 


BODILY    DEFORMITIES. 


or  other  bone  ;  but  it  may  also  be  applicable  to  genu 
valgum  or  varum,  though  I  know  of  no  case  in  which 
it  has  been  put  into  practice,  and  should  think  that  the 
large  incision  necessary,  and  the  time  occupied  in  the 
operation,  must  be  strong  objections.  Linear  osteotomy  is 
in  every  way  preferable. 

Osteoclasy. — This  consists  in  breaking  the  bone  or 
bones  with  a  machine  and  without  external  wound.  If  a 
wound  communicating  with  the  bone   can  be  done  away 


Figs.  125  and  126. — Severe  double  genu  valgumbefore  and  after  diaphysial  osteotomy. 


with,  and  at  the  same  time  a  good  correction,  without  serious 
damage  to  the  soft  parts  be  obtained,  this  plan  will  supersede 
osteotomy.  It  is,  like  almost  everything,  an  old  method, 
and  the  osteoclasts  of  Hippocrates,  Apelles,  Archimedes, 
Paul  of  ALgina,  and  the  more  modern  ones  of  Louvrier, 
Bosch,  .^Esterlen,  Blasius,  Rizzoli,  Bruns,  Volkmann, 
Esmarch,  Collin,  and  Robin  will  be  found  figured  and  de- 
scribed in  various  ancient  and  modern  surgical  works  and 
monographs.  In  pre-chloroform  days  the  method  must 
have  been  a  brutal  one,  and  even  in  more  modern  times  it 


GENU    VALGUM    AND    OSTEOTOMY.  283 

has  been  rough  and  unsurgical,  in  that  it  lacked  precision,  and 
this  is  one  great  reason  that  osteotomy,  as  now  performed, 
was  preferred  to  it.  The  old  methods  of  osteotomy  with 
open  wound  were  given  up  because  of  the  bad  results,  until 
the  subcutaneous  plan  was  discovered  ;  and  it  may  be  that 
the  almost  forgotten  old  plans  of  osteoclasy  will  be  per- 
manently revived  and  practised  if  good  results  be  obtained. 
V.  Robin  has,  during  the  last  two  years,  rendered  it  more 
accurate,  through  the  use  of  a  new  instrument  constructed 
according  to  his  own  views,  and  has  published*  some 
excellent  results  on  nine  cases  of  genu  valgum. t  Mr. 
Schramm,  the  well-known  orthopaedic  instrument  maker 
of  64,  Belmont  Street,  Chalk  Farm  Road,  constructed  for 
me  an  osteoclast,  which  appeared  to  be  in  every  way  prefer- 
able to  previous  ones,  but  as  yet  the  instrument  needs  per- 
fecting as  our  trials  were  not  satisfactory. 

Weak  knees. — Surgeons  in  orthopaedic  practice  are 
often  consulted  about  this  condition  which  consists  in  a 
feebleness  and  giving  in  of  the  knee  on  its  inner  side,  and 
appears  to  be  due  to  ligamentous  laxity,  and  especially  of 
the  internal  lateral  ligament.  If  left  uncorrected,  an  atonic 
genu  valgum  will  result.  The  patients  usually  complain  of 
discomfort,  rather  than  pain,  and  inability  to  stand  or  walk 
for  long.  Such  joints  are  usually  felt  to  be  looser  than 
normal  ones  and  are  liable  to  severe  sprains  from  any  trivial 
accident.  They  are  best  treated  by  rest,  massage,  tonics, 
elastic  knee-caps,  or  light  instrumental  supports. 

*  "Lyon  Medical,"  1882;  also,  "  Traitement  du  Genu  Valgum," 
&c,  1882. 

+  At  the  Copenhagen  meeting  of  the  International  Medical  Con- 
gress, Robin  stated  that  nearly  one  hundred  limbs  had  been  successfully 
rectified  by  his  instrument,  which  is  superior  to  that  of  Colin. 


284  BODILY    DEFORMITIES. 


CHAPTER   XVII. 

GENU    VARUM    AND    CURVED    TIBLE. 

Definition.— This  is  the  opposite  condition  to  knock- 
knee,  and  consists  in  a  greater  or  less  separation  between 
the  thigh  and  leg  bones  when  the  subject  of  it  is  standing 
or  lying  with  the  limbs  fully  extended. 

Synonyms.  —  Latin,  Genu  Varum  or  Extrorsum  ; 
Greek,  Exogonyacon ;  English,  Bow-legs,  Bandy-legged; 
French,  Genou  en  dehors ;  German,  Sabelbein,  O-Bein, 
Sichelbein. 

Varieties.— It  may  be  single  or  double,  the  latter  being 
commoner,  and  usually  one  limb  is  more  bowed  than  the 
other.  The  single  form  may  be  secondary  to  genu  valgum, 
or  valgum  may  follow  on  a  primary  varum,  and  be  a  result 
of  the  shortening  of  the  varoid  member,  producing  a  com- 
pensatory inward  or  valgoid  yielding  of  its  fellow. 

Causes. — These  are  the  same  as  in  genu  valgum,  but 
rickets  is  a  much  more  frequent  ^etiological  factor  than  an 
atonic  condition  of  the  muscles  and  ligaments. 

Pathology.— Rickets,  though  a  constitutional  affection, 
affects  chiefly  the  bones,  and  these  often  unequally,  so  that 
.the  spine  and  thorax  may  be  deformed  and  the  limbs 
remain  free,  or  the  tibiae  and  fibulae  may  be  affected,  and 
the  thigh  bones  remain  free,  or  the  lower  end  of  the  femur, 
with  or  without  the  upper  end  of  the  tibia,  may  be  diseased, 
producing  genu  valgum  or  varum  ;  or  the  shafts  of  the  long 


GENU    VARUM    AND    CURVED    TIBIAE.  2S5 

bones  may  be  affected,  and  genu  varum,  or  curved  leg 
bones,  or  both,  may  result.  Not  only  may  individual 
bones  be  attacked  while  others  remain  free,  but  the  viru- 
lence or  intensity  of  the  pathological  process  may  vary 
considerably,  and  this  rachitic  condition  of  the  bones  is 
the  predisposing  cause,  whereas  the  body-weight  in  walk- 
ing and  standing  produces  the  curvature,  the  direction  of 
which  will  depend  on  (1)  the  part  of  the  bone  which  is 
softest,  (2)  on  the  normal  structure  and  curvature  of  the 
bone,  it  being  naturally  weaker  at  some  points  than  others, 
and  (3)  on  the  direction  through  which  the  pressure  is 
transmitted  through  them. 

This  deformity  involves,  usually,  a  larger  area  than  does 
genu  valgum,  but  the  seat  of  greatest  convexity  is  at  or 
about  the  knee,  which  is  thrown  beyond  the  centre  of 
gravity,  so  that  a  straight  line  from  the  middle  of  the 
femoral  head  to  the  centre  of  the  ankle-joint  would  fall 
inside  the  knee,  and  the  extent  of  the  bowing  depends  not 
only  on  the  amount  of  the  deformity  but  also  on  the  bone 
or  bones  affected,  and  on  the  portions  of  them  which  are 
deformed.  It  may  be  slight,  or  moderate,  or  it  may  nearly 
form  a  circle,  and  in  the  severest  forms,  which,  fortunately, 
are  rare,  the  leg  bones  may  be  at  an  acute  angle  to  the 
femur  and  the  feet  may  be  crossed,  or  the  patient  may 
walk  on  the  outer  border  of  the  foot  and  external  malleolus. 
The  feet  are  sometimes  flat,  and  in  severe  cases  one  or  both 
may  be  in  a  varoid  state. 

In  cases  where  all  the  leg  bones  are  affected  there  is  a 
general  outward  curvature  of  the  limb  or  limbs,  but  when 
situated  at  the  lower  end  of  the  femur  the  greatest  con- 
vexity is  at  the  knee.  The  external  condyle  may  be 
elongated  and  laterally  enlarged,  and  the  external  tibial 
tuberosity  also  enlarged,  and  the  external  lateral  ligament  or 
tendon   of   the   biceps   elongated.     In   some    cases,   and 


286  BODILY    DEFORMITIES. 

especially  in  rachitic  ones,  the  joint  line  is  oblique  from 
within,  down  and  out,  and  the  ligaments  loose.  The  lower- 
ing of  the  external  condyle  may  be  due  to  the  outward 
curve  at  the  lower  end  of  the  femur,  or  it  may  reside,  as  in 
the  opposite  deformity,  largely,  or  in  part,  in  the  condyle 
itself.  In  some  few  cases  the  femur  may  be  straight,  but 
the  leg  bones  bent  and  the  knee  ligaments  lax. 

If  the  bow  be  below  the  knee,  which  is  a  common  con- 
dition, it  may  be  due  to  a  sharpish  bend  outwards  of  the 
shaft  at  its  junction  with  the  upper  epiphysis,  and  in  such 
cases  a  depression  can  readily  be  felt  at  this  spot,  and  the 
overhanging  inward  projection  of  the  internal  tibial  tuber- 
osity can  be  clearly  made  out.  In  some  few  cases  an 
abnormal  spine  may  be  felt  at  the  outer  side  of  the  upper 
part  of  the  tibia.  A  very  common  condition  in  this 
deformity  is  an  outward  curvature  of  the  leg  bones  at  their 
lower  third,  but  this  is  not  the  most  important  factor  in  the 
production  of  bow-legs,  though  the  deformity  is  aggravated 
by  it.  Seeing  that  the  stress  of  the  body-weight  comes  on 
the  lower  end  of  the  tibia,  which  is  between  the  point  of 
resistance,  i.e.,  the  foot,  and  the  femur  which  transmits  the 
weight  from  above,  it  would  be  more  correct  to  say  that  the 
internal  malleolus  is  pressed  inwards,  carrying  the  outer  with 
it,  and  causing  a  curve  or  bend  with  its  concavity  inwards 
at  the  slenderest  part  of  the  tibia ;  but  if  this  part  resist,  or 
have  yielded,  the  next  point  of  pressure-stress  is  at  the 
upper  part  of  the  bones,  and  the  angle  already  spoken  of 
in  this  situation  becomes  formed.  In  cases  where  the  whole 
deformity  lies  below  the  knee,  the  curve  in  the  tibia  may  be 
near  the  middle  or  at  either  end,  the  upper  being  more  com- 
monly affected  in  true  genu  varum.  If  the  femur,  and 
upper  and  lower  parts  of  the  tibia  be  curved,  as  is  some- 
times the  case,  they,  with  the  muscles  covering  them,  not 
uncommonly  give  the  appearance  of  a  somewhat  interrupted 


GENU    VARUM    AND    CURVED    TIBLE. 


287 


single  curve  ;  but  sometimes  there  is  one  prominent  curve, 
and  the  others,  if  present,  are  slight,  and  may  be  unnoticed, 
without  careful  examination.  The  tibiae  will  often  be  found 
flattened  laterally,  producing  the  platycnemic  tibiae  peculiar 
to  some  lower  races.  The  fibula  almost  always  shares  in 
the  deformity. 

Genu  varum  of  one  side  and  valgum  of  the  other  may 
occur  in  the  same  individual,  though  this  condition  is  not 
nearly  so  common  as  double  varum  or  valgum.  In  such 
cases  there  may  be  pelvic  or  spinal  deformity,  which,  how- 


Figs.  127  and  128.-  Genu  extrorsum  in  a  girl  aged  nine,  before  and  after  diaphysial 

osteotomy. 


ever,  is  not  usually  very  marked  in  young  people.  Some- 
times, in  operating  on  these  cases,  one  femur  may  be  found 
harder  than  the  other,  and  one  curve,  whether  in  or  out,  is 
generally  secondary  or  complimentary  to  the  other.  If  the 
changes  in  these  cases  be  confined  to  the  femur,  it  must 
be  recollected  that  changes  in  the  length  and  obliquity  of 
the  femoral  neck  may  considerably  aid  in  producing  the 
deformity. 

Symptoms.— The  altered  height  of  the  individual,  and 
the  peculiarity  of  the  aspect  and  gait  of  the  patient  are 
noteworthy,  and  it  will  generally  be  found  in  cases  of  the 


288 


BODILY    DEFORMITIES. 


combined  form,  i.e.,  valgum  and  varum,  that  the  subject 
walks  more  firmly  and  steadily  on  the  bowed  leg  than  on 
the  valgoid.  Both  deformities  disappear  in  complete 
flexion.  In  many  cases  of  rickety  genu  varum  the  exter- 
nal condyles  will  be  found  lower  down  than  the  inner,  and 
the  joint  oblique  from  within,  down  and  out.  The  explana- 
tion of  the  disappearance  of  the  deformity  is  similar  to  that 
given  in  the  chapter  on  genu  valgum. 


Figs.  129  and  130. — Severe  genu  varum  in  a  young  man  aged  ninteen,  before  and  after 
external  condylotomy.     The  oblique  position  of  the  joint  is  shown. 


Treatment— In  the  first  and  second  stages  of  the 
rachitic  deformity,  which  is  commonest,  removing  the  body- 
weight,  and  the  use  of  suitable  lateral  splints  or  apparatus, 
may,  in  young  subjects,  correct  the  deformity,  but  I  have 
too  often  found  that  even  in  children  of  three  to  four  years 
of  age,  this  treatment  is  of  no  avail.  I  always  adopt  it, 
however,  as  a  routine  practice  before  resorting  to  osteotomy. 
In  moderate  cases  it  will  be  sufficient  to  divide  the  femur 


CURVED    TIBIA    AND    FIBULA.  289 

at  its  lower  third,  but  if  the  tibiae  be  also  much  curved  these 
will  have  to  be  subsequently,  or  simultaneously,  corrected. 
If  the  external  condyle  be  much  elongated,  external  condy- 
lotomy,  I  have  found,  to  thoroughly  correct  the  deformity. 


CURVED    TIBIA    AND    FIBULA. 

These,  as  met  with  in  orthopaedic  practice,  are  almost 
always  due  to  rickets,  and  are  commonly  met  with  before 
the  age  of  five.  If  unchecked,  they  may  go  on  increasing 
in  severity,  or  they  may  remain  stationary  for  a  time  and 
then  subsequently  increase.  The  direction  and  position  of 
the  curve  varies  in  different  cases.  It  is  commonest  at  the 
lower  third  of  the  leg  bones,  and  as  an  outward  deviation, 
but  there  may  be  a  simple  anterior  curvature,  or  an  antero- 
external.  Rarer  forms  are  the  antero-internal,  a  severe 
instance  of  which,  combined  with  genu  valgum,  is  shown  in 
an  ensuing  figure.  The  tibiae  in  many  cases  are  found 
compressed  or  flattened  from  side  to  side,  resembling 
the  platycnemic  tibiae  of  some  lower  races.  The  fibulae 
usually  assume  the  same  curve,  but  in  some  exceptional 
cases  they  remain  straight.  In  severe  cases  of  antero-inter- 
nal curvature,  where  the  body-weight  is  to  a  great  extent 
borne  by  the  bent  bone,  bursae  may  form  and  may  inflame 
and  suppurate.  In  some  instances,  the  entire  tibia  is  bent 
anteriorly  or  antero-laterally,  and  the  tendo-Achillis  much 
shortened.  The  foot  may  be  either  in  a  valgoid  or  varoid 
position. 

Treatment.— In  early  stages,  removal  of  the  body-weight 
and  the  application  of  properly  fitting  splints  of  various 
materials  are  of  service,  but  generally,  the  deformity  is  set 
when  the  surgeon  sees  the  case,  so  that  osteotomy  or  osteo- 
clasy,  are  the  only  means  of  effecting  correction  of  the 
curvature.      I  have,  in  most  cases,  found  that  a  simple 

u 


290 


BODILY    DEFORMITIES. 


linear  osteotomy  from  before  backwards,  with  division  of 
the  tendo-Achillis,  if  necessary,  is  sufficient  to  correct,  or  to 
very  much  improve,  the  deformity,  and  this  latter  result  I 
prefer  to  adopting  cuneiform  osteotomy,  which  involves  a 
larger  operation,  and  a  much  longer  convalescence.  In 
some  severe  cases  it  may  be  necessary  to  remove  a  wedge  of 
bone,  and  as  it  is  desirable  only  to  remove  as  much  bone  as 
is  necessary  to  correct  the  curvature,  it  will  be  well  to  adopt 


Figs.  131  and  132. — Very  severe  case  of  curved  tibiae  and  fibulae  and  genu  valgum 
before  and  after  multiple  osteotomy.  The  tibiae  and  fibulae  were  first  corrected,  and 
six  weeks  after,  diaphysial  osteotomy  for  correction- of  the  in-knee  was  done. 


McEwen's  plan  of  ascertaining  the  size  of  the  wedge.  He 
places  the  limb  on  its  side  and  takes  a  tracing  of  the 
anterior  border  of  the  tibia,  then  he  measures  the  breadth 
of  this  bone  from  before  backwards  at  the  most  prominent 
part  of  the  convexity,  and  draws  a  second  line  parallel  to 
the  former,  and  corresponding  to  the  breadth  measured  ; 
the  shape  is  then  cut  out,  and  the  paper  folded  at  the  most 
prominent  part  of   the  convexity.      The  fold  has  to  be 


CURVED    TIBIA    AND    FIBULA.  20  [ 

wedge-shaped,  with  its  base  anteriorly,  and   it  should  be 
altered  until  the  pattern  has  become  straight.     The  base  of 
the  wedge  will  represent  the  size  of  the  cuneiform  portion 
to  be  removed,  then  the  distance  is  marked  and  fixed  on  a 
pair  of   callipers,  which  may  be   applied  to  the  bone,  if 
necessary.     An  incision  sufficiently  long  to  admit  the  finger 
and  callipers  is  to  be  made,   and   the  wedge  removed  by 
means  of  a  chisel,  and  not  an  osteotome.   The  chisel  should 
have  a  clean  cutting  edge  and  be  bevelled.    A  wedge  smaller 
than  that  required  should  be  first  removed,  and  then  from 
either  side  extra  shavings  may  be  taken  to  the  necessary 
extent.     The  bony  incisions  on  each  side   should  be  per- 
fectly smooth.     The  periosteum  should  be  raised  from  the 
bone  before  applying  the  chisel,  not  only  to  ensure  more 
complete  filling  up   of   the  gap,   but  also  to  protect  the 
neighbouring    soft    parts.      When    the    wedge    has    been 
removed,  and  the  wound  cleansed  from  all  bony  fragments, 
the  fibula  may  be  broken,   if   possible,   or  osteotomized, 
when  the  limb  must  be  put  in  position  and,  if  necessary,  the 
tendo-Achillis  divided.       In  placing  the  anterior  surfaces 
together,  care  must  be  taken  not  to  include  muscles  between 
the  bones,  as  this  may  result  in  non-union,  or  suppuration. 
St.  Germain  has  recently  devised  an  osteotome  which  will 
remove  a  wedge  of  various  sizes,  and  more  accurately  than 
can  be  done  by  the  use  of  an  ordinary  chisel.     In  the  rarer 
cases  of  twisted  tibiae  it  may  be  necessary  to  do  an  oblique 
osteotomy,  either  down,  or  in,  or  from  before,  backwards,  or 
even,  to  do  more  than  one  osteotomy,  before  the  limb  can 
be  straightened.     The  after-treatment  is  the  same  as  for 
compound  fracture. 


u  2 


292  BODILY   DEFORMITIES. 


CHAPTER  XVIII. 

congenital    misplacements   and    deficiencies    of  the 

lower  limb. 

Congenital  Malpositions  of  the  Hip. 

Of  all  congenital  displacements  this  is  the  commonest, 
and  it  is  to  be  considered  rather  as  a  joint  malformation 
than  a  dislocation  proper.  This  deformity  has  been  termed 
congenital  dislocation,  but  as,  in  the  majority  of  cases,  there 
originally  was  no  complete  contact  between  the  joint  sur- 
faces, the  term  "  dislocation  "  is  quite  inapplicable. 

Definition. — This  malady  consists  in  certain  conditions 
which  cause  an  abnormality  of  position  between  the  femoral 
and  acetabular  surfaces,  one,  or  both  of  which,  are  insuffi- 
ciently developed.  The  ligaments  of  the  joints  are  usually 
abnormal. 

Varieties. — There  may  be  a  true  form  of  coxal  dis- 
location due  to  the  accoucheur's  efforts  to  turn,  or  deliver, 
during  childbirth ;  but  the  forms  of  congenital  malposition 
are  various,  and  depend  upon  conditions  which  will  be 
explained  in  the  paragraph  on  pathology.  It  may  be  single, 
or  double,  the  latter  being  the  commoner,  and  is  much  more 
frequent  in  girls  than  in  boys,  though  I  know  of  no  very 
satisfactory  explanation  of  either  of  these  occurrences. 
The  displacement  up  and  back  on  to  the  dorsum  ilii  is  by 
far  the  commonest,  though  the  up  and  forwards  or  ilio-pubic, 


CONGENITAL    MISPLACEMENTS    OF    THE    LOWER    LIMB.       293 

and  the  upwards  or  supra-cotyloid  displacements,  do  occur, 
but  are  usually  associated  with  conditions,  such  as  mon- 
strosity, which  do  not  admit  of  treatment.  There  is  a  class 
of  congenital  partial  dislocations,  or  sub-luxations,  which  is 
commonly  associated  with  idiocy  or  paralysis.  These  may 
often  be  reduced  without  great  difficulty,  but  owing  to  the 
general  conditions  just  mentioned,  the  surgeon's  efforts  are 
of  little  avail. 
Causes  and  Pathogenesis. — Many  hypotheses  have  been 


Fig.  133. — Congenital  double  hip  displacement  in  a  young  woman  seen  from  behind. 

offered  in  explanation  of  the  occurrence  of  this  deformity. 
Some  attribute  it  to  maternal  impression,  others  to  defective 
development,  or  to  a  bad  intra-uterine  position  of  the  foetus, 
which  may  be  independent  of,  or  concomitant  with,  an  abnor- 
mal narrowness  of  the  uterus,  cramped  by  the  presence  of 
twins  or  triplets,  or  it  may  be  due  to  efforts  at  extraction 
during  birth.  Dupuytren*  thought  that  the  hip  capsule 
was   too  long  in  these  cases,  permitting  of  ready  displace- 

*  "  Lecons  Orales  de  Clinique  Chirurgicale. " 


294  BODILY    DEFORMITIES. 

ment.  Breschet  considered  that  the  head  of  the  femur  is 
at  fault,  being  insufficiently  developed  or  absent,  and  thus 
easily  displaced.  Volkmann  and  Broca  attribute  it  to  the 
articular  surfaces  not  being  developed  opposite  each  other, 
and  thus  not  permitting  of  proper  apposition,  and  the 
latter  eminent  surgeon  also  thought  that  a  defect  in  nutri- 
tion and  local  ossification,  was  the  cause  of  the  deformity. 
Hippocrates,  Dupuytren,  and  Cruveilhier  were  all  of 
opinion  that  this  deformity  is  caused  by  an  abnormal  posi- 
tion of  the  foetus  in  utero  ;  and  Roser  thought  that  this 
incorrect  position  of  the  foetus  caused  excessive  adduction 
of  one  or  both  femora,  and  thus  produced  the  deformity. 
Others  have  thought  that  it  maybe  due  to  the  gradual  pres- 
sure of  the  mother's  clothes,  or  stays,  or  by  the  sudden 
pressure  or  shock,  of  blows  or  falls.  Guerin,  Carnochin, 
and  others  have  ascribed  it  to  muscular  retraction  asso- 
ciated with  pathological  conditions  of  the  nervous  system  ; 
and  others,  my  colleague,  Mr.  Brodhurst,  among  them,  to 
a  purely  mechanical  cause,  i.e.,  to  the  "  downward  force 
applied  to  the  thigh  in  endeavouring  to  hasten  the  birth  in 
breach  presentations."*  Verneuil,  and  Dally  concurring 
with  him,  regard  some  of  these  cases  as  not  being  really 
congenital,  but  as  being  produced  after  birth  by  a  paralytic 
atrophy  of  the  hip  muscles,  and  especially  of  the  gluteals, 
as  the  result  of  infantile  paralysis.  Sayref  attributes  the 
malformation  entirely  to  deficiency  of  development  of  the 
acetabulum,  though  he  does  not  give  any  pathological  evi- 
dence of  this  being  the  sole  cause.  Intra-uterine  disease 
of  the  joint,  looseness  of  the  coxo-femoral  ligaments  (Sedil- 
lot),  arthritis,  and  hydrarthrosis,  have  also  been  regarded  as 
causes,  in  individual  cases.    Having  had  the  opportunity  of 

*  "Lectures  on  Orthopaedic  Surgery,"  Second   Edition,    p.    160. 
London,  1876. 

t  "Lectures  on  Orthopaedic  Surgery,"  p.  344.     London,  1876. 


CONGENITAL    MISPLACEMENTS    OF    THE    LOWER    LIMB.       295 

seeing  a  large  number  of  these  cases  in  my  practice  at  the 
Royal  Orthopaedic  Hospital,  and  in  that  of  the  London 
Hospital,  and  the  East  London  Children's  Hospital,  during 
many  years  past,  and  having  been  much  interested  in  them, 
I  have  made  careful  examinations,  and  have  also  diligently 
studied  the  accounts  of  dissections  which  have  been  made, 
of  cases  in  which  a  post-mortem  was  obtained.  I  have 
thus  been  led  to  adopt  an  eclectic  conclusion,  viz.,  that 
different  cases  have  a  different  aetiology  ;  and  I  am  at  present 
inclined  to  regard  defective  development  as  the  commonest 
cause,  and  mechanical  force  in  delivery  as  not  very  frequent, 


Fig.  134. — Right  congenital  hip  malposition.     Anterior  view. 

though  I  do  not  deny  that  any  of  the  other  named  causes 
may  be  active  in  particular  cases,  or  that  more  than  one 
cause  may  be  at  work  in  any  individual  instance. 

In  cases  of  defective  development,  the  fault  may  reside 
in  the  acetabular  part  of  the  os  innominatum,  and  then  it 
can  only  be  satisfactorily  made  out  after  dissection;  but  I 
have  been  able  to  detect  abnormality  in  the  head  of  the 
femur,  in  several  cases,  during  life,  and  in  others  it  has 
apparently  been  normal.  When  affected,  the  head  is  usually 
atrophied,  but  may  be  hypertrophied,  the  latter  appearing 
to  be,  in  my  experience,  not  very  uncommon,  and  I  imagine 


296  BODILY   DEFORMITIES. 

this  is  due  to  the  difficulty  the  misplaced  bone  is  subjected 
to  in  muscular  efforts  to  accommodate  itself  to  its  altered 
position,  and  to  carve  out  a  new  acetabulum.  The  irrita- 
tion and  friction  consequent  on  this  leads  to  increased 
activity  of  growth,  and  thus  results,  hypertrophy  of  the 
femoral  head.  In  defective  development,  the  bony  or  liga- 
mentous parts  of  the  joint  are  usually  primarily  at  fault,  and 
muscular  contraction  and  shortening  are  secondary.  Three 
conditions  may  be  present,  either  singly,  or  more  or  less 
combined,  viz.,  1,  incomplete  formation  of  the  acetabulum, 
or  ossification  of  the  os  innominatum  may  be  normal ;  2, 
the  joint  surfaces  may  not  be  vis-a-vis  to  each  other  ;  or,  3, 
the  ligaments  may  be  lax  or  deficient,  and  permit  of  ready 
displacement  of  the  femoral  head,  through  muscular  action, 
or  other  force. 

I  cannot  doubt,  however,  that  efforts  at  delivery  have 
produced  hip  dislocations  ;  and  in  one  case  I  know  of,  frac- 
ture of  the  thigh  was  thus  produced.  But,  judging  from  my 
own  cases,  and  from  others  I  have  read  or  heard  of,  I  can- 
not agree  with  my  colleague,  Mr.  Brodhurst,  when  he  says, 
"  The  cause  of  congenital  dislocation  of  the  hip,  as  it 
usually  presents  itself,  is  a  purely  mechanical  one.  This 
dislocation  never  occurs  except  after  preternatural  labour, 
and  it  occurs  especially  with  the  presentation  of  the  nates," 
because  I  have  made  special  inquiries  as  to  this  point,  and 
in  many  of  the  cases  have  failed  to  elicit  any  difficulty  in 
childbirth  necessitating  unusual  manual  or  instrumental 
aid.  C.  Hueter*  is  also  of  this  opinion,  and  he  denies 
that  a  traumatic  dislocation  can  occur  at  this  period  of  life, 
but  in  this  statement  I  cannot  agree  with  him.  These 
obstetric  dislocations,  accompanied  as  they  must  be  by  lacera- 
tion of  the  ligaments,  are  traumatic  luxations  rather  than 
what  is  ordinarly  understood   as  congenital    displacment. 

*  "Klinik  der  Glenkkrankheiten,"  Erster  Theil,  p.  326.     1876. 


CONGENITAL    MISPLACEMENTS    OF    THE    LOWER    LIMB.       297 

As  regards  Verneuil's  theory,  that  the  displacement  is 
in  several  cases  secondary  to  paralysis  of  the  circumcoxal 
muscles,  my  experience  leads  me  to  concur  that  paralysis 
may  lead  to  dislocation  of  the  hip ;  but  this  is  quite 
exceptional.     As   I  speak  of  this  subject  further  on  in  this 


Fig.  135.— Left  congenital  displacement  in  a  man  aged  twenty-nine. 


volume,  I  need  only  here  remark  that  congenital  paralytic 
luxation  I  have  never  seen ;  and  it  must  be  recollected  that 
attention  is  usually  only  drawn  to  the  deformity  after  the 
child  has  begun  to  walk,  so  that  if  paralysis  pre-existed, 
progression  without  aid  would  either  be  impossible,  or 
would  be  of  a  character  so  different  from  the  rolling  gait  of 


\ 


298  BODILY    DEFORMITIES. 

congenital  malposition,  that  there  should  be  no  diagnostic 
difficulty.  Guerin  and  Carnochin's  view  of  active  muscular 
spasmodic  retraction,  as  causing,  not  only  congenital  dislo- 
cations, but  all  other  congenital  articular  deformities,  cannot 
be  borne  out  by  the  facts,  as,  excepting  these  writers,  no 
one  else  seems  to  have  met  with  this  muscular  affection.  I 
would  not  deny  that  spasmodic  muscular  hip-contraction  may 
be  congenital,  for  I  have  seen  it,  though  I  have  never  seen 
it  as  a  cause  of  congenital  hip  displacement ;  and  though  I 
doubt  not  that  the  muscles  may,  and  do,  become  secondarily 
shortened,  and  more  or  less  rigid,  and  ultimately  wasted, 
still  I  cannot,  from  my  own  experience,  assert  that  they  are 
primarily  contracted,  or  that  they  cause  the  deformity  by 
their  abnormal  action,  independently  of  any  articular  or 
ligamentous  deformity. 

Heredity  seems  to  play  a  somewhat  important  produc- 
tive part  in  some  instances  of  congenital  hip  misplace- 
ments, as  in  other  deformities  ;  but  in  most  of  the  cases  I 
have  seen,  the  deformity,  whether  single  or  double,  was  un- 
complicated with  such  history,  or  with  other  malformations. 
Brodhurst*  saw  three  children  of  one  family,  one  had  the 
right  femur  displaced,  another,  the  left,  and  also  pes  varus, 
and  the  third,  had  both  bones  displaced.  The  sex  is  not 
given. 

Vallette  considers  that  hereditary  influence  explains  the 
relative  frequency  of  this  deformity  in  certain  parts  of  the 
world,  for  it  is  rare  in  the  north  of  France,  but  is  much 
more  frequent  in  the  upper  regions  of  the  river  Loire.  I 
have  seen  two  cases,  occurring  in  girls,  one  of  which  was 
sent  to  me  by  my  colleague  at  the  East  London  Children's 
Hospital,  Dr.  Eustace  Smith,  in  which  the  mother  was 
similarly  affected.  In  one  case,  parent  and  child  had 
double  dislocation,  in  the  other,  the  mother  had  single,  and 
*  Op.  tit.,  p.  161. 


CONGENITAL    MISPLACEMENTS    OF   THE    LOWER    LIMB.       299 

the  child  double  displacement.  Tillmann*  came  to  the  con- 
clusion, from  a  dissection  which  he  made,  that  this  mal- 
formation was  due  to  a  very  strongly  developed  ligamentum 
teres,  which  dragged  the  head  of  the  femur  out  of  place. 
It  may  be,  that  during  development,  a  very  strongly 
developed  ligamentum  teres  may  have  this  effect ;  but 
ligaments  are  more  passive  than  active,  and  I  cannot  readily 
understand  Tillmann's  explanation,  unless  bony  deformity, 
or  muscular  action  were  superadded.  Moreover,  bearing  in 
mind  the  attachment  of  this  ligament,  if  it  were  active,  it 
would  tend  to  displace  the  head  of  the  bone  down,  instead 
of  upwards.  The  explanation  of  this  deformity,  like  that 
of  others,  and  of  its  greater  frequency  on  both  sides  than 
on  one,  may  probably  be  that  there  is  some  central  median 
deficiency,  or  even  disease,  in  the  spinal  cord ;  or  some 
error  in  the  vascular  supply,  which  is  incompatible  with 
complete  development.  In  the  case  of  single  malformation, 
the  nervous  or  vascular  lesions  would  probably  be  uni- 
lateral. Sex  is  undoubtedly  a  predisposing  cause,  as  this 
affection  is  much  more  common  in  girls  than  in  boys, 
though  the  infantile  and  juvenile  pelvis  is  but  slightly 
different  in  the  two  sexes.  At  present,  I  know  of  no  satis- 
factory explanation  of  this  occurrence. 

The  case  of  left  deformity,  shown  in  the  last  figure,  died 
in  the  London  Hospital.  He  was  admitted  for  ulceration 
of  the  rectum  and  diarrhoea.  This  and  the  laryngeal  affec- 
tion, which  killed  him,  were  syphilitic.  He  was  a  West 
Indian  sailor  and  was  in  the  hospital  a  year  before  under 
Mr.  Jonathan  Hutchinson,  who  wished  to  excise  the  joint 
under  the  belief  that  the  case  was  one  of  traumatic  dislo- 
cation, the  man  having  fallen,  but  falls  were  not  uncommon 
with  him,  and  were  due  to  the  weakness  of  the  limb.  Mr. 
Lipscombe,  the  house  surgeon,  and  I  dissected  the  limb, 
*  "Arch,  der  Ileilkunde,"  B.  XVI.      1873. 


:oo 


BODILY   DEFORMITIES. 


and  found  that  the  head  of  the  femur  was  very  rudimentary 
and  nodulated,  and  the  neck  short.  There  was  no  aceta- 
bulum, but  a  projection  in  its  place,  which  was  quite  solid. 
Above  this,  there  was  a  slight  depression  on  the  dorsum  ilii, 
with  irregular  cartilaginous  deposit,  forming  an  incomplete 
socket.      There  was  no  Hgamentum  teres,  and  the  femur 


Figs.  136,  137,  and  138. — Posterior  and  right  and  left  profile  views  of  a  case  of  con- 
genital hip  displacement  in  a  girl.  The  lordosis  and  prominent  abdomen,  are  well 
shown. 


was  kept  loosely  in  place  by  the  gluteal  muscles  over  it, 
which,  with  a  little  thickened  fascia,  acted  as  the  joint 
capsule. 

Symptoms.— These  will  vary  according  as  the  lesion  be 
uni-  or  bi-lateral,  and  as  the  latter  is  more  common,  I  will 
first  consider  the  symptoms  produced  by  it.  In  double 
deformity,  the  gait  is  characteristic,  the  patient,  in  walking, 


CONGENITAL    MISPLACEMENTS    OF    THE    LOWER    LIMB.       30 1 

rolls  from  side  to  side,  balancing  and  raising  herself  or 
himself,  on  the  anterior  and  lower  part  of  the  feet,  and  in- 
clining the  upper  part  of  the  trunk — which  is  usually  held 
backwards — to  that  member  which  is  sustaining  the  body- 
weight.  In  running,  the  subject  rolls  less  than  in  walking, 
because  the  more  energetic  contraction  of  the  hip  muscles 
fixes  the  femoral  heads  more  tightly  in  their  sockets,  and 
thus  allows  the  body  to  be  held  more  upright.  Young 
children  hold  up  their  arms  in  order  to  balance  themselves. 
The  trochanter  of  the  side  on  which  the  body  rests  in  pro- 
gression ascends  towards  the  iliac  crest,  either  because  the 
muscles  and  ligaments  which  unite  the  femur  to  the  in- 
nominate bone  yield  directly  the  body-weight  rests  on  the 
limb  in  use,  or  because  the  iliac  expansion  is  at  a  greater 
inclination  on  that  side,  through  the  peculiarity  of  gait.  In 
fact,  in  single  and  in  double  misplacements,  the  anatomical 
peculiarities  of  this  deformity  are  increased,  or  exaggerated, 
when  the  patient  is  standing,  walking,  or  running.  Ana- 
tomical examination  reveals  that  the  femoral  head  cannot 
be  felt  through  the  groin  ;  that  the  great  trochanters  are 
much  above  the  Roser-Nelaton  test-line,  i.e.,  from  the 
anterior  superior  iliac  crest  to  the  lower  part  of  the  tuber 
ischii ;  that  they  are  unduly  prominent,  as  well  as  higher, 
than  natural ;  and  that  the  femoral  head,  if  present,  pro- 
jects beneath  the  glutei,  usually  above  and  behind  the  coty- 
loid cavity,  and  may  readily  be  felt  on  rotation,  which  elicits 
a  masked  or  cartilaginous  crepitus,  that  may  be  heard 
and  felt :  and  if  the  limb  be  flexed  and  extended,  it  will  be 
observed  that  the  head  of  the  femur  describes  arcs  of  a 
circle.  The  femora  are  not  infrequently  on  different  levels 
on  the  two  sides,  which  may  be  due  either  to  the  different 
extent  of  the  deformity,  or  to  varying  muscular  action,  or 
to  the  habit  of  standing  more  on  one  leg  than  on  the 
other,  thus  pushing  it  more  up  on  the  more  used  side. 


302 


BODILY    DEFORMITIES. 


The  lower  limbs  are  more  or  less  flexed  either  at  the 
hips,  or  knees— which  latter  are  usually  in  slight  valgus, 
owing   to    the    upper   ends    of    the    femora 


being 


more 


separated  than  usual ;  and,  not  infrequently,  there  co-exists 
pes  valgus,  which  is  secondary  to  the  change  of  axis  of  the 
limb.  The  trunk  has  a  length  quite  disproportionate  to 
that  of  the  limbs,  appearing  much  longer  than  normal,  and 
the  limbs  shorter.  As  a  result  of  this  apparent  shortening 
of  the  thighs,  the  ends  of  the  fingers 
correspond  to  the  external  condyles, 
or  may  even  pass  below  them,  whilst 
in  well-formed  children,  the  fingers  only 
reach  the  junction  of  the  middle  and 
lower  femoral-thirds.  The  muscles  of 
the  lower  limb  are  ill-developed,  from 
insufficient  use,  although  subjects  of 
this  deformity  are  fairly  active  and  can 
get  about  for  moderate  distances  with- 
out pain,  though  they  are  somewhat 
easily  tired.  In  the  recumbent  posi- 
tion, the  pelvis  being  fixed,  the  limbs 
may  usually  be  drawn  down  to  their 
proper  length,  but  relapse  as  soon  as 
the  extending  force  is  withdrawn. 
Passive,  as  well  as  active  motion,  show 
that  the  movements  of  the  joint  are  free, 
with  the  exception  of  abduction,  which  is  limited,  adduction 
being  increased.  The  abdomen  is  strongly  curved  forwards, 
the  thighs  at  their  upper  and  inner  parts  are  separated, 
and  pass  obliquely  down  and  in,  while  the  legs  pass  in  a 
contrary  direction.  The  pelvis  is  rendered  very  oblique, 
the  pubis  being  carried  down  and  forwards,  and  the  sacrum 
raised,  while  the  lumbar  and  lower  dorsal  vertebrae  are 
curved  forwards,  causing  an  extreme  lordosis,  and  increasing 


Fig,  139. —  Congenital 
malposition  of  right  hip 
in  an  infant.  Right  pro- 
file view. 


CONGENITAL    MISPLACEMENTS    OF    THE    LOWER    LIMB.       303 

the  abdominal  prominence.  This  lordosis  is  very  marked 
in  dorsal  decubitus,  though  in  some  cases  it  is  considerably- 
diminished.  The  distance  between  the  anterior  superior 
iliac  spines  and  the  symphisis,  is  shorter  than  natural,  and 
the  gluteal  folds  are  much  less  marked  than  normal,  though 
the  buttocks  are  elevated  and  project  strongly  when  stand- 
ing. The  breadth  of  the  hips  is  increased  owing  to  the 
projection  of  the  great  trochanters.  If,  in  infants  and 
young  children,  the  finger  be  passed  into  the  rectum  a 
fissure  may,  in  some  cases,  be  detected  in  the  os  innominatum 
at  the  seat  of  the  acetabulum. 

On  examining  the  patient  from  behind,  a  well-marked 
lumbar  lordosis  will  be  observed,  and  sometimes  this  is  so 
extreme  as  to  form  an  angle,-  instead  of  a  curve.  The 
spinal  muscles  are  often  atrophied,  the  great  trochanters 
will  be  found  raised  and  usually  placed  more  posteriorly 
than  normal,  and  this  deformity  is  generally  more  marked 
on  one  side  than  on  the  other.  In  profile,  the  limb  posi- 
tion, the  spinal  curve,  and  the  protuberant  abdomen,  will 
be  more  noticeable,  and  inclination  of  the  pelvis  down  and 
forwards  will  be  found  to  exist,  the  object  of  which  is  to 
establish  equilibrium  in  standing.  The  pelvic  inclination, 
and  the  lordosis,  will  become  more  evident  if  the  child  be 
placed  upon  its  back,  and  it  will  be  found  that  the  move- 
ments of  the  limb,  with  the  exception  of  abduction,  are 
preserved.  In  many  cases,  the  patient  cannot  flex  the  leg 
so  as  to  bring  the  thigh  in  contact  with  the  abdomen.  If 
strong  abduction  be  voluntarily,  or  passively,  attempted,  the 
opposite  side  of  the  pelvis  will  be  raised,  and  turned 
towards  the  moving  side.  The  adductors  are  almost  always 
contracted.  In  most  cases,  the  fingers  placed  in  the  groin 
will  fail  to  find  the  femoral  head  on  movement.  If  the 
pelvis  be  fixed,  and  the  affected  limbs  be  drawn  on,  they 
can,  as  already  stated,  be  elongated,  and  when  relaxed,  the 


304  BODILY    DEFORMITIES. 

upper  portion  of  the  bone  will  rise,  so  that  the  trochanters 
are  very  nearly  on  a  level  with  the  iliac  crest,  or  only  slightly 
below  it. 

In  unilateral  displacement,  the  walk  assumes  a  different 
aspect,  and  is  more  of  an  oscillating  nature,  so  that  when 
the  foot  touches  the  ground,  the  trunk  is  drawn  to  the  same 
side,  the  thigh  appears,  as  it  were,  driven  into  the  pelvis, 
and  the  hip  is  lower  than  the  opposite  one.  The  malformed 
limb  is  shorter  and  more  slender  than  its  neighbour,  and 
directed  inwards,  and  the  lumbar  spine  is  inclined  towards 
the  opposite  side,  so  as  to  bring  the  centre  of  gravity  in  its 
proper  position.  In  unilateral  displacement,  secondary 
malformations  of  the  pelvis,  which  are  of  importance 
obstetrically,  are  produced.  In  double  deformity  the 
antero-posterior  pelvic  diameter  is  greater  than  natural,  and 
labour  is  easy,  but  in  unilateral,  the  ilium  is  pushed  towards 
the  opposite  side,  and  modifications  of  the  superior  outlet 
are  produced.  Naegele,  Gueniot,  Verrier,  and  Champneys, 
have  drawn  attention  to  these  secondary  pelvic  deformities. 
Some  of  these  patients  walk  in  equinus  on  the  affected  side, 
others  walk  on  the  entire  sole  and  flex  the  knee  of  the 
sound  side,  and  in  such  cases  the  peculiarity  in  walking  is 
more  noticeable.  In  nearly  all  cases  the  pelvis  on  the 
malformed  side  is  placed  more  anteriorly  in  walking,  and 
the  knee  of  this  side  often  touches  the  opposite  one,  and 
tends  to  cross  it.  While  running,  the  peculiarity  of  gait 
is  less  noticeable,  because  the  muscles  are  more  energeti- 
cally contracted  and  fixed  to  the  femoral  head.  If  the 
patient  be  lying,  the  affected  limb  will  be  shorter  than  its 
neighbour,  there  will  be  a  hollow  in  the  groin,  the  trochanter 
will  be  higher  than  the  Roser-Ne'laton  test-line,  the  remains, 
of  the  femoral  head  will  be  felt  beneath  the  atrophied 
muscles  and  the  ilium,  in  the  commonest  form  of  dislocation, 
and  a  peculiar  crepitation,   or  friction  sound,  will  be  felt. 


CONGENITAL    DISPLACEMENTS    OF   THE    LOWER    LIMB.       305 


in  most  cases,  during  flexion,  extension,  and  rotation  ;  and 
it  will  be  found  that  the  femoral  head,  or  its  remains,  if 
present,  will  describe  arcs  of  a  circle.  The  anterior  superior 
iliac  spine  of  the  affected  side  will  be  found  on  measure- 
ment nearer  the  symphysis  pubis  than  on  the  opposite,  the 
gluteal  fold  is  higher  and  less  marked,  and  there  will  be 
some  prominence  in  the  corresponding  iliac  fossa,  due  to 
its  having  been  bulged  forwards  and  inwards  during  growth, 
by  the  displaced  head  of  the  femur.  Adduction  will  be  in- 
creased, abduction  diminished.    The  foot  may  be  in  various 


Figs.  140  and  141.  — -Left  congenital  hip  malposition.     Anterior  and  posterior  views. 

positions,  inverted,  straight,  or  turned  outwards,  and  I  have 
observed  that  these  are  valuable  signs  in  diagnosing  the 
presence  or  absence  of  the  femoral  head  or  neck,  for  when 
these  are  present  inversion  is  the  rule,  when  absent  eversion 
exists.  Extension  increases  the  length  of  the  displaced 
limb,  but  never  makes  it  equal  to  the  opposite  one.  The 
lumbar  spine  is  convex  anteriorly  and  to  the  luxated  side. 

Complications. — Neuralgic  pains  along  the  sciatic  or 
the  anterior  crural  are  sometimes  complained  of,  and  may 
be  due  to  stretching  or  compression  of  these  nerves.  The 
new  false  joints  may  spontaneously,  or  after  a  fall,  inflame, 

x 


306  BODILY    DEFORMITIES. 

and  may  lead  to  diagnostic  mistakes,  such  as  confounding 
it  for  pathological  dislocation  ;  and  in  cases  coming  under 
care  later  in  life,  it  may  be  thought  that  dislocation  has 
occurred,  and  if  the  crepitation,  already  mentioned,  co-exist, 
the  case  may  be  confounded  with  one  of  fracture  and  dorsal 
dislocation. 

Diagnosis.— This  is  usually  not  difficult,  if  the  patient  be 
seen  within  a  year  or  two  of  its  first  walking  ;  but  in  infants, 
and  in  some  cases  which  have  been  overlooked,  or  passed 
unobserved  until  a  later  period  of  life,  certain  difficulties 
may  arise.  In  infants,  by  accurate  measurements  and 
manipulations,  this  deformity  may  be  made  out,  but  usually 
the  existence  of  any  abnormality  is  not  noticed  until  the 
child  begins  to  walk,  and  then  the  question  arises  between 
joint  mischief  and  infantile  paralysis,  which  latter  may 
occur  during  the  early  months  of  existence ;  but  even  in 
such  cases,  it  is  rarely  that  the  surgeon's  attention  is  drawn 
to  them  until  the  child  has  attempted  to  walk,  when  the 
parents,  noticing  the  peculiarity,  bring  it  for  treatment.  It 
is  usually  easy  to  differentiate  it  from  morbus  coxae,  and 
careful  examination  will  diagnose  it  from  paralysis.  In 
some  cases  of  single  dislocation  the  child  cannot  walk 
without  support,  and  then  the  peculiar  gait  may  disappear. 
In  cases  occurring  later  in  life,  the  history  and  the  presence 
of  a  similar  deformity  in  the  parents,  and  especially  in  the 
mother,  will  be  of  service  in  distinguishing  it  from  patho- 
logical or  traumatic  dislocations.  But  the  latter  are  so  rare 
in  children  that  they  may  almost  be  dismissed  from  consider- 
ation, though  separation  of  the  epiphysis  of  the  head  of 
the  femur,  or  epiphysitis  of  the  head  or  great  trochanter, 
may  and  do  occur,  and  may  give  rise  to  diagnostic  diffi- 
culty. The  absence  of  pain  at  the  hip  or  knee,  and  on 
communicated  movement,  and  the  absence  of  enlarged 
inguinal    glands,    will    serve   to    distinguish    it    from   hip 


CONGENITAL    DISPLACEMENTS    OF    THE    LOWER    LIMB.       307 

disease.  Mr.  Holmes,  in  his  work  upon  "  Diseases  of 
Children,"  correctly  says,  that  in  congenital  luxation  the 
shortening  may  disappear  of  itself,  or  after  a  slight 
extension,  and  that  voluntary  or  communicated  move- 
ments are  easy,  rapid,  and  without  pain,  and  that  what- 
ever position  be  given  to  the  limb,  one  may  follow,  easily, 
the  movements  of  the  displaced  bone. 


Figs.  142  and  143. — Double  congenital  hip  malposition  in  a  woman  who  had   had 
children.      Seen  from  the  front  and  behind. 

If  the  patient  be  seen  between  five  or  ten  years  of  age, 
or  later,  the  parents  will  have  observed  its  peculiar  walk, 
and  also  that  the  child  often  falls  about.  In  such  cases, 
difficulty  will  only  arise  in  unilateral  lesion,  then  the 
question  will  be  between  coxitis,  diastasis  of  the  epiphysis 
of  the  head  of  the  femur,  and  traumatic  or  paralytic  dis- 
location ;  but  careful  examination  will  suffice  to  diagnose 

x  2 


308  BODILY   DEFORMITIES. 

between  these  affections.  If,  on  the  other  hand,  the  child 
has  walked  fairly  well,  and  it  has  lately  become  feverish 
and  kept  its  bed,  and  then  more  or  less  lost  its  power  of 
motion,  and  walked  with  a  limp,  the  question  will  be 
between  coxitis  and  paralytic  dislocation  ;  but  the  existence 
of  paralysis  will  be  enough  to  distinguish  between  these 
affections.  Hysteria,  or  malingering,  which  is  not  uncom- 
mon in  children,  and  especially  in  young  girls,  may  give 
rise  to  doubt  as  to  the  nature  of  the  affection,  but  the 
ordinary  tests  for  this  malady  will  help  us  in  clearing  up 
doubts.  Other  sources  of  difficulty  have  been  given  in  the 
paragraph  on  complications. 

Prognosis. — This  varies  according  as  we  regard  it  from 
the  prospect  of  alleviation  or  cure.  There  is  never  any 
risk  to  life,  except  such  as  may  accrue  from  the  instability  of 
the  patient  leading  to  accidents.  Unilateral  displacement 
leads  to  pelvic  deformity,  which  may  more  or  less  seriously 
complicate  childbirth,  and  thus  the  prognosis  may  become 
of  life-importance  in  these  subjects,  though  even  in  them 
the  deformity  is  not  often  of  very  serious  import.  As 
already  pointed  out,  the  capsule  becomes  elongated  and 
hypertrophied  until  it  has  reached  its  limits  of  extension, 
so  that  it  then  remains  in  statu.  It  should  be  borne  in 
mind  that  a  severe  accident  may  thrust  the  upper  part  of 
the  bone  through  the  capsule,  and  so  lead  to  the  idea  of  a 
dorsal  dislocation,  unless  the  previous  history  of  the  case 
be  known. 

Treatment.— This  is  palliative  and  curative,  but  if  the 
patient  be  beyond  puberty,  there  is  little  to  be  done  beyond 
relieving  the  deformity.  My  opinion  is,  that  in  the  large 
majority  of  cases,  anything  other  than  palliative  measures, 
such  as  the  use  of  appropriate  apparatus  for  grasping  the 
trochanters,  and  keeping  them  as  far  as  possible  in  place,  is 
of  little  use.     Pravaz  claimed  to  have  made  cures  by  the 


CONGENITAL   DISPLACEMENTS    OF    THE    LOWER    LIMB.       309 

use  of  his  special  apparatus,  but  Bouvier,  and  others,  have 
fairly  shown  that  these  were  not  permanent  cures.  As 
regards  operative  measures  for  the  relief,  or  cure,  of  this 
deformity,  I  can  say  nothing  from  personal  experience,  and 
seeing  that  the  pathological  conditions  differ  more  or  less 
in  almost  every  case,  I  can  expect  little  from  any  proceed- 
ings yet  devised  in  the  way  of  making  a  firmer  and  stronger 


Fig.  144.— Instrument  for  double  congenital  hip  displacement. 


joint.  Mr.  Brodhurst  records  a  case  in  which,  after  con- 
sultation with  Mr.  T.  Holmes,  he  divided  the  tendons 
attached  to  the  great  trochanter  with  considerable  benefit. 
Though  I  have  seen  quite  a  large  number  of  these 
deformities,  I  have  never  felt  that  I  could  offer  any  hope 
of  permanent  relief  by  any  operation  which  I  could  devise, 
or  which  I  have  read  of,  so  that  I  have  been  content  either 
to  leave  the  deformity  to  itself,  or  to   apply  appropriate 


3IO  BODILY    DEFORMITIES. 

mechanical  apparatus.  These,  if  properly  measured  for, 
and  regularly  worn,  may,  in  the  case  of  young  children,  do 
a  good  deal  to  prevent  the  elongation  of  the  capsule,  and 
the  further  displacement  of  the  bone  towards  the  iliac 
crest. 

I  may  here  mention  that,  in  some  cases  of  fissure  of  the 
abdominal  wall,  the  femoral  head  is  found  displaced,  and 
the  vesical  distension,  which  is  a  very  likely  cause  of  the 
non-union  of  the  abdominal  wall,  causes  separation  of  the 
pubic  rami,  and  the  altered  direction  and  imperfect  growth 
of  the  pelvic  bones,  cause  shallowness  of  the  acetabulum 
and  consequent  slipping  out  of  the  femoral  head. 

Lumbo-sacral  spondylolisthesis  may  cause  diagnostic  diffi- 
culty, as  some  of  the  symptoms,  especially  the  lordosis,  are 
similar.  Valuable  papers  on  this  subject  have  been  written 
by  Neugebauer  and  Swedelni,*  and  the  last  volume  of  the 
Transactions  of  the  Obstetrical  Society  contains  a  good 
paper  on  the  subject. 

*  Archiv  ficr  Gynakologie,  B.  xxii.  H.  II,  and  abstract  in  Medical 
Times,  September  6,  1884,  p.  333. 


[  I 


CHAPTER  XIX. 

DEFORMITIES    OF    THE    TOES. 

Causes. — These  are  very  rarely  congenital,  and  the  acquired 
forms  are  generally  the  result  of  muscular  or  fascial  con- 
tractions, or  are  due  to  mechanical  causes,  and  though  of 
less  importance  than  similar  affections  of  the  fingers,  are, 
nevertheless,  entirely  worthy  of  the  surgeon's  attention  on 
account  of  the  hindrance  to  progression  which  they  so  -com- 
monly produce.  The  prime  cause  may  be  mechanical,  and 
the  muscular  and  ligamentous  retraction  secondary.  Scars 
of  burns,  diseases  of  the  bones  and  joints,  gout,  rheumatism, 
and  the  various  forms  of  dactylitis,  and  paralysis,  may  pro- 
duce them  ;  but  we  shall  here  specially  deal  with  those 
affections  which  commonly  come  under  the  observation  of 
the  orthopaedic  surgeon. 

Varieties. — The  toes  may  be  displaced  transversely,  or 
vertically,  the  former  being  the  more  common,  and  the  big 
and  little  toes  being  usually  affected,  more  especially  the 
former,  which  condition  is  known  as  Hallux  valgus.  The 
great  toe  may  also  be  drawn  toward  the  mid-line  of  the 
body,  and  separated  from  its  fellows  :  this  is  termed  Hallux 
varus  or  Pigeon-toe,  and  is  sometimes  an  independent  affec- 
tion, and  at  others  associated  with  talipes  varus.  The 
great  toe  may  over-  or  under-lie  its  neighbours,  when  the 
affection  may  be  termed  Over-toe  or  Under-toe.  In  vertical 
contractions,  the  bulb  of  the  last  phalanx,  and  sometimes 


12  BODILY    DEFORMITIES. 


the  nail  itself,  rests  upon  the  ground.     This  condition  is 
known  as  Hammer-toe. 


TRANSVERSE   DISPLACEMENT   OF   THE   TOES. 

Hallux  valgus.  Symptoms. — The  patient  complains 
of  difficulty  in  walking,  and  pain,  usually  at  the  seat  of 
the  metatarso-phalangeal  articulation,  and  sometimes  of 
cramps  of  the  foot,  occurring  chiefly  at  night.  The  toes  may 
perspire  freely  in  the  inter-spaces,  and  corns  and  bunions 
over  the  metatarso-phalangeal  joint  complicate  the  affec- 
tion. On  examination,  the  great  toe  will  usually  be  found 
displaced  outwards  at  a  varying  angle,  overlapping  the 
second,  and  part  of  the  third  toe.  In  rarer  cases,  it  is  on 
the  inferior  or  plantar  aspect  of  these.  Similar  malposi- 
tions may  affect  the  little,  and  sometimes  the  other  toes. 
Hammer-toe  sometimes  complicates  these  cases,  as  an 
accommodative  effort  of  the  neighbouring  toes,  to  make 
room  for  the  great  toe. 

Causes. — This  transverse  deviation  of  the  toes,  and 
especially  the  outer  deviation  of  the  great  toe,  has  been 
attributed  to  the  pressure  of  improperly  made  boots. 
Camper  states,  that  during  standing  and  walking,  the  tarsal 
arch  flattens  and  the  foot  elongates,  so  that  the  heel  is 
pushed  backwards,  and  the  toes  forwards.  If  the  boots  be 
sufficiently  long  and  broad,  the  toes  are  properly  accommo- 
dated, but  if  they  be  short,  the  toes  are  pushed  obliquely 
backwards,  and  the  big  toe,  being  generally  the  longest,  is 
the  first  to  become  deviated,  and  as  the  boot  will  not  allow 
it  to  be  turned  inwards,  it  is  turned  outwards  over  the  other 
toes,  because  the  boot-sole  and  the  upper  leather,  in  most 
cases,  prevent  its  being  displaced  beneath  its  neighbours. 
The  other  toes  crowd  one  upon  the  other  and  converge 
towards  the  axis  of  the  foot,  which  is  through  the  second 


TRANSVERSE    DISPLACEMENT    OF   THE    TOES. 


3T3 


metatarsal  bone,  and  form  two  layers,  one  dorsal  and  one 
plantar. 

Malgaigne  does  not  accept  this  view,  but  explains  the 
deformity  through  muscular  retraction,  the  effect  of  rheu- 
matism and  gout,  and  to  the  influence  of  the  bursae,  and  the 
enfeeblement  of  the  internal  lateral  ligament.  Dubreuil 
believes  in  muscular  contraction  or  retraction,  secondary  to 
the  pressure  of  the  shoes,  or  other  causes,  excepting  the 
diatheses,  which  act  directly  through  the  muscles ;  and  if 
Ave  consider  that  were  the  cause  always  a  badly  fitting  boot, 
one  should  meet  more  frequently  with  the  deformity  among 


Figs.  145  and  146. — To  left,  is  transverse  deviation  of  right  great  and  little  toes  with 
hammer-toes  and  bunions  ;  to  the  right,  the  left  great  toe  overrides  its  neighbours. 


the  well-to-do,  than  among  the  poor,  who  do  not  study 
the  shape  of  the  boot  so  long  as  they  are  able  to  walk 
comfortably.  But  this  deformity  is  often  seen  in  the  post- 
mortem and  dissecting-room  ■  and  though  it  may  be  said  that 
we  should  find  it  equally,  if  not  more  frequently,  among  the 
middle  and  upper  classes  if  post-mortems  were  as  frequent 
in  them,  still  there  can  be  no  doubt  of  its  commonness 
among  the  poor,  who,  as  a  rule,  do  not  wear  tightly  fitting 
boots  for  the  greater  part  of  the  day. 

Moreover,  if  one  reflect  as  to  what  should  be  the  resultant 
action  of  muscles  which  move  the  great  toe,  and  if  one 
compare  its  abductors  and  adductors   (to  the  mid-line  of 


314  BODILY    DEFORMITIES. 

the  body),  the  predominance  of  the  former  will  be  evident, 
for  it  has  the  extensor  proprius  and  flexor  longus  hailucis, 
the  innermost  tendon  of  the  dorsalis  pedis,  the  transverse 
hallucis,  and  the  adductor,  (which  is  an  abductor  from  the 
mid-body-line)  all  as  abductors ;  whereas  it  has  but  one 
muscle  to  draw  it  to  the  median  body-line,  the  abductor 
hallucis,  which  is  more  a  flexor  than  an  adductor.  In 
standing,  in  consequence  of  the  predominance  and  normal 
tonicity  of  these  abductors,  the  great  toe  has  a  tendency  to 
incline  outwards,  and  the  more  the  muscles  act,  the  more 
the  abductors  overcome  the  adductor,  and  the  outer  devia- 
tion of  the  toe  will  become  more  manifest ;  and  among  the 
poorer  working  classes,  the  increased  use  of  these  muscles, 
which  their  calling  commonly  necessitates,  will  probably 
explain  the  greater  frequency  of  this  deformity  among  them. 

The  arrangement  of  the  muscles  of  the  little  toe,  which 
has  a  long  flexor,  which  also  adducts  it  to  the  mid-line  of 
the  body,  and  an  extensor  tendon,  which  has  a  similar  effect, 
to  counterbalance  the  abductor  minimi-digiti,  permits  the 
inward  displacement  of  this  tendon  to  be  explained  on 
muscular  grounds,  and  the  shape  of  the  boot,  moreover, 
would  tend  to  facilitate  this  displacement  of  it,  as  well  as 
the  outer  displacement  of  the  great  toe.  The  intermediate 
toes  may  be  laterally  displaced,  but  these  are  consecutive 
to  those  of  the  outer  and  inner  toes,  so  that  there  can  be 
no  doubt  that  muscular  action  is,  at  any  rate,  a  powerful 
predisposing  cause  ;  but  I  think  that  most  often  the  exciting 
cause  resides  in  improperly  constructed  boots. 

Pathology. — Broca  first  accurately  studied  these  devia- 
tions with  special  reference  to  the  great  toe.  I  have  had 
the  opportunity  of  dissecting  several  of  these,  and  can 
vouch  for  the  accuracy  of  his  paper.  The  head  of  the 
first  metatarsal,  which  has  for  sometime  ceased  to  be  covered 
at  its  inner  part  by  the  base  of  the  first  phalanx,  is  deprived 


TRANSVERSE   DISPLACEMENT    OF    THE   TOES. 


3*5 


of  cartilage  in  that  part  which  is  not  in  contact  with  the 
phalanx.  The  internal  lateral  ligament  is  much  elongated, 
and  the  anterior  end  of  the  metatarsal  bone  is  drawn 
inward,  while  the  phalanges  are  drawn  outwards  ;  the  meta- 
tarsal also  undergoes  a  rotation  on  its  axis  from  above  and 
out,  downward  and  inwards.  A  serous  bursa  becomes  deve- 
loped over  the  inner  part  of  the  metatarso-phalangeal  joint 
through  the  friction  of  the  shoes,  and  this  leads  to  a 
thickening  of  the  skin  and  callosity,  and  sometimes  to  a 


Fig.  147. — Apparatus 
to  correct  transverse 
deviation  of  great  toe. 


Fig.  148.— Sandal  with  cog-wheel 
and  key  for  hallux  varus. 


corn  forming  over  a  bunion,  of  which  the  bursa  is  the 
centre.  This  bursa  may  communicate  with  the  cavity  of 
the  joint  in  some  cases,  and  should  it  inflame,  it  may  lead 
to  articular  destruction.  From  continued  pressure  and 
irritation,  the  nerves  of  this  part  are  very  sensitive  and 
hypertrophied,  and,  through  unequal  pressure  on  the  last 
phalanx,  ingrowing  toe-nail,  or  onychia,  may  result,  or  hyper- 
trophy of  the  nail ;  and  these  are  commonest  among  those 
who  are  not  cleanly  with  their  feet,  and  who  neglect  to  trim 


3  l6  BODILY    DEFORMITIES. 

their  toe-nails.     Sometimes  rheumatism  or  gout  may  com- 
plicate these  changes. 

Treatment. — In  early  stages,  the  wearing  of  properly 
made  boots,  i.e.,  of  sufficient  length  and  breadth,  combined 
with  rest,  and  relief  of  pressure,  will  suffice  to  effect  a  cure  ; 
but  ordinarily  a  light  apparatus,  to  be  worn  day  and  night, 
is  necessary.  In  later  stages,  it  is  well  to  try  drawing  the 
tee  as  nearly  as  possible  into  proper  position  and  fixing  it 
with  strapping  to  the  adjoining  toe,  placing  a  pad  of  lint  or 
cotton- wool  between  them.  In  some  cases,  a  special  sole, 
with  a  properly  shaped  projection  between  the  affected  toe 
and  its  neighbour,  will  suffice.  A  V-snaPed  block  fixed  to 
the  sole  and  fitted  between  the  toes  is  often  of  service. 
The  apparatus  shown  in  the  annexed  figures  are  very  useful 
in  the  severe  forms,  and  they  sufficiently  explain  them- 
selves ;  others  have  been  constructed,  some  of  which  do 
not  allow  of  progression  ;  others  limit  the  movement  of 
the  toes  in  the  sense  of  flexion  and  extension ;  but  these,  if 
properly  constructed,  can  be  worn  inside  a  largish  boot, 
and  will  usually,  in  time,  correct  the  deformity  in  many 
cases.  Tenotomy  of  the  transversus  pedis  and  first  plantar 
interosseus  will  be  necessary  if  these  means  fail. 

In  cases  complicated  with  inflamed  corns  and  bunions, 
these  must  be  treated  on  ordinary  surgical  principles,  and 
if  the  bursse  have  inflamed  and  communicate  with  the 
joint,  the  question  of  producing  anchylosis  of  the  joint, 
which,  if  bony,  would  be  a  hindrance  to  walking,  must  be 
balanced  against  excision  or  amputation.  In  some  cases, 
when  there  is  no  inflammation,  and  a  fair  trial  of  these 
machines  has  not  been  productive  of  complete  benefit, 
tenotomy  of  the  external  lateral  metatarso-phalangeal  liga- 
ment, and  of  any  tendon  displacing  the  toe,  must  be 
adopted,  previous  to  resorting  to  more  radical  measures, 
such  as  osteotomy,  excision,  or  amputation.    Mr.  Barker  has 


VERTICAL    DISPLACEMENT    OF    THE    TOES.  317 

recorded  in  the  Lancet  of  April  12,  a  case  of  cuneiform 
osteotomy  for  hallux  valgus,  and  states  that  the  operation 
was  suggested  to  him  by  Mr.  C.  Hoar,  a  student  at  Uni- 
versity College. 

Hallux  varus  or  Pigeon-toe. — This  is  the  opposite 
deformity  to  hallux  valgus,  and  in  it  the  great  toe  is  deviated 
to  the  mid-line  of  the  body  and  drawn  away  from  its 
fellow. 

Causes. — It  may  arise  independently,  but  may  compli- 
cate pes  equino-varus.  I  have  also  seen  it  in  severe  genu 
valgum,  and  then  it  appears  due  to  expansion  of  the  toes, 
in  order  to  get  a  firmer  grasp  of  the  ground  during  progres- 
sion. It  may  also  be  due  to  contraction  of  the  abductor 
hallucis,  and  it  may  be  a  premonitory  symptom  of  a  form 
of  paralysis  which  leads  to  spastic  or  rigid  contraction  and 
retraction,  producing  first  varus,  and  then  equinus. 

Symptoms. — The  deformity  is  obvious,  and  the  patient 
complains  of  difficulty  in  getting  a  boot  on,  of  cramps  on 
the  inner  side  of  the  foot,  and  of  pain  after  walking  or 
standing. 

Treatment. — A  sandal  with  an  arrangement  to  keep 
the  toe  in  place  should  first  be  tried.  Disease  of  the 
nervous  system,  if  present  must,  of  course,  be  treated. 
Electricity,  massage  and  manipulations,  if  indicated  should 
have  a  fair  trial,  and,  finally,  tenotomy  of  the  abductor 
hallucis  may  be  needed. 


VERTICAL   DISPLACEMENT    OF   THE    TOES. 

Varieties. — These  may  be  of  three  kinds;  (1)  the  whole 
digit  may  be  flexed  ;  (2)  or  it  may  be  extended;  or  (3)  the 
first  phalanx  may  be  in  extension,  and  the  others  in  flexion. 

Causes. — These  are  mechanical,  muscular,  and  nervous. 
The  former  are  due  to  short  boots  cramping  the  toes  in 


318  BODILY   DEFORMITIES. 

a  flexed  condition  ;  the  second  may  be  due  to  primary  or 
secondary  contraction  and  retraction  of  muscles,  and  the 
last  are  seen  in  paralytic  cases,  and  especially  in  the  great 
toe,  the  first  phalanx  of  which  is  extended  and  the  second 
flexed.  A  rare  cause  is  contraction  of  the  digital  prolonga- 
tions of  the  plantar  fascia.  This  malady  may  be  also 
congenital  or  hereditary,  when  it  oftenest  occurs  in  the 
second  or  little  toes.  It  may  also  result  from  prolonged 
disuse  of  the  lower  limb,  especially  when  a  paralyzed 
patient  lies  for  a  long  time  on  the  back  and  the  weight  of 
the  clothes  is  borne  on  the  toes ;  the  flexors  may  then 
become  retracted.  A  predisposing  cause  exists  in  those 
whose  second  toes  are  longer  than  the  first. 

Symptoms. — Difficulty  and  pain  on  walking,  usually 
referred  to  the  prominent  joint,  and  to  the  balls  of  the  toes, 
which  are  the  points  of  greatest  pressure  and  friction,  and 
corns  and  callosities  may  form,  and  complicate  the  affection. 
On  examination,  the  extensor  tendon  will  be  found  stretched 
over  the  metatarso-phalangeal  joint,  and  on  attempting  to 
straighten  the  toes,  the  flexors  will  commonly  be  tightly 
stretched. 


FLEXION    OF    THE    TOES. 

This  may  be  partial  or  complete :  in  the  former  the 
second  or  third  phalanx  is  affected,  or  both  together.  It  is 
extremely  rare  for  the  proximal  phalanx  to  be  flexed  on  the 
metatarsal,  except  in  old  paralytic  cases  of  equinus. 

Treatment. — This  must  depend  upon  the  cause.  If 
due  to  badly  fitting  boots  such  must  be  corrected,  and  a 
sole  or  sandal,  with  slits  between  the  toes,  and  straps, 
buckles,  or  strapping,  fastened  over  them  to  fix  them  down, 
must  be  worn,  and  this  can  be  easily  done  if  the  boot  be 
made  to  lace  up    the    middle   as    far    as    the  metatarso- 


EXTENSION    OF    THE    TOES.  319 

phalangeal  joint.  When  the  muscles  are  shortened,  teno- 
tomy of  the  contracted  tendons  will  be  necessary,  followed 
by  subsequent  gradual  stretching,  and  in  paralytic  cases, 
manipulations,  galvanism  and  retentive  apparatus,  should 
be  tried,  before  tenotomy  is  resorted  to.  The  accompany- 
ing figures  of  apparatus,  which  I  have  found  serviceable, 
may  be  worn  for  some  time  before  operation  is  attempted, 
and  especially  at  night.  The  illustrations  sufficiently 
explain  themselves. 

When  tenotomy  of  the  flexors  is  necessary,  both  of  them 
should  be  divided  subcutaneously  at  the  same  time,  and  if 
gradual  extension  do  not  remove  the  deformity,  and  if  pain 


Figs.  149  and  150. — Sandal  with  spring  and  one  with  loops  for  hammer-toes. 

and  inconvenience  remain,  the  question  of  exsecting  a  por- 
tion of  the  tendon,  or  even  of  amputation  of  the  affected 
toes,  will  have  to  be  considered. 

EXTENSION    OF   THE    TOES. 

Extension  of  the  Entire  Toe. — This  may  affect  one 
or  several  toes,  but  especially  the  first,  which  is  at  the 
same  time  displaced  outwards. 

The  causes  and  symptoms  are  similar  to  those  producing 
flexion. 

Treatment. — This  is  similar  to  the  preceding,  in  early 
stages,  but  in  old  or  severe  cases,  tenotomy,  or  even  excision 


320  BODILY    DEFORMITIES. 

of  the  portion  of  the  affected  extensor  tendon  may  become 
necessary.  In  performing  the  latter  operation,  the  tendon 
is  cut  down  upon,  the  skin  flaps  retracted,  and  the  part  of  it 
nearest  the  muscle  should  first  be  divided  ;  for  if  the  distal 
portion  be  first  cut,  it  may  retract,  and  the  difficulty  of  find- 
ing it  will  complicate  the  operation.  In  the  worst  cases, 
especially  if  bad  corns  or  bunions  have  formed,  amputation 
may  become  necessary. 

EXTENSION    OF    THE    FIRST    PHALANX    AND    FLEXION    OF 
THE    OTHERS. 

Hammer-Toes. — In  this  deformity,  the  first  phalanx  is 
drawn  towards  the  dorsum  of  the  foot  and  it  forms  an  angle, 
open  superiorly,  with  the  corresponding  metatarsal,  while 
the  two  remaining  phalanges  are  strongly  flexed.  This  con- 
dition is  known  as  hammer-toe.  If  the  great  toe  be  thus 
affected,  the  ungual  phalanx  is  alone  flexed.  In  some  cases, 
the  heel  is  somewhat  drawn  up  and  the  foot  broadened. 
and  during  walking,  which  is  done  with  difficulty,  the  toes 
spread  and  their  balls  appear  to  grasp  the  ground  as  in  the 
case  illustrated,  which  was  taken  from  a  woman  aged  thirty- 
three,  and  was  neurotic,  and  probably  congenital  in  origin, 
as  she  said  she  had  always  had  it,  and  her  mother  confirmed 
the  statement.  I  was  inclined  to  think  it  might  be  due  to 
some  infantile  nervous  affection.  The  more  prominent  toes 
had  corns  over  the  interphalangeal  joints. 

Symptoms. — The  projecting  angle  formed  at  the  joint 
between  the  second  and  distal  phalanges  becomes  subject 
to  the  friction  and  pressure  of  the  boot,  and  a  corn  forms, 
under  which  a  serous  bursa  may  develop,  and  this  is 
separated  from  the  joint  only  by  the  extensor  tendon. 
Should  this  corn  and  bursa  inflame,  an  abscess  may  form 
in  the  bursa,  and  this  may  burst  and  leave  a  fistulous  open- 


EXTENSION    OF    THE   TOES. 


321 


ing  externally,  or  it  may  communicate  with  the  joint  and 
lead  to  its  destruction.  In  advanced  cases,  there  is  pro- 
nounced swelling  and  redness  about  the  articulation,  while 
the  proximal  phalanx  appears  considerably  diminished  in 
size.  The  pressure  of  the  ball  of  the  last  phalanx  on  the 
sole  of  the  boot  may  produce  abrasions  of  them  and 
severe  pain,  and  may  also  lead  to  inflammation  about  the 
nail.  Corns  may  also  form  over  the  bulb  of  the  toes,  and 
if  they  inflame,  may  seriously  complicate  matters. 
Pathology. — Boyer  considered  that  this  deformity  was 


Figs.  151  and  152. — Both  feet  of  a  patient  (see  text)  the  subject  of  congenital 

hammer-toes. 


due  to  the  simultaneous  retraction  of  the  extensors  and 
flexors.  Mr.  Nunn*  thinks  that  some  of  the  plantar  muscles 
are  involved.  I  have  seen  a  few  cases  which  were  due  to 
contraction  of  the  plantar  fascia  alone  and  were  cured  by 
its  division.  In  most  cases  the  deformity  is  secondary  to 
mechanical  causes,  as  already  described,  and  in  others  it  is 
an  indication  of  nervous  disease  acting  through  the  muscles. 
Treatment. — In  early  stages  this  is  similar  to  that  given 
for  the  other  deformities  in  flexion  and  extension,  but,  if 

*  "  Trans.  Clin.  Soc."  vol.  xi.  p.  153. 


322 


BODILY    DEFORMITIES. 


these  do  not  suffice,  tenotomy,  or  excision  of  a  portion  of 
the  extensor  tendon,  may  be  necessary.  Goyrand  has 
divided  the  flexors  and  was  able  to  partly  correct  the  defor- 
mity, but  there  remained  an  angular  tendency  at  the  joint 
between  the  distal  and  second  phalanges.  I  have  most 
often  divided  the  extensors,  and  with  appropriate  subse- 
quent treatment  have  succeeded  in  correcting  the  defor- 
mity, but  in  some  severe  cases  I  have  also  had  occasion  to 


F,G.  153.— An  infant  with  congenital  occipital  encephalocele,  whose  hands  and  feet 
were  much  deformed,  and  are  represented  in  the  next  illustration  but  one,  and  in  the 
chapter  on  the  fingers. 

divide  the  flexors  when  the  deformity  has  been  entirely 
overcome.  I  should,  in  all  cases,  first  try  tenotomy  of  the 
extensor,  and  this  failing  I  should  resort  to  excision  of  a 
portion  of  the  affected  extensor  tendon,  or  to  tenotomy  of 
the  flexors,  with  gradual  subsequent  correction  of  the  defor- 
mity. In  the  above-mentioned  case,  three  weeks  after 
tenotomy  of  the  extensors  and  the  use  of  splints,  \  forcibly 
stretched  the  flexors,  which  yielded  with  an  audible  noise. 


EXTENSION    OF   THE   TOES. 


23 


The  foot  was  put  up  in  Paris  plaister,  the  toes  being 
fixed  in  the  corrected  position.  Passive  motion  of  the  toes 
was  adopted  in  three  weeks  after  the  operation,  and  subse- 
quently both  Achillis  tendons  were  divided.  The  result 
was  very  satisfactory.  In  the  severest  cases,  where  there  is 
inflammation  and  joint  or  bone  disease,  amputation  is  the 
best  resource. 

Syndactylism  and  Polydaetylism. — The  causes  of 
these  are  similar  to  those  described  in  the  chapter  on  the 
hand.  Acquired  union  of  the  toes  is  the  result  of  burns. 
Webbing  of  the  toes  does  not 
usually  call  for  operation,  and 
if  operation  be  necessary, 
similar  plans  to  those  recom- 
mended in  the  section  just 
named,  may  be  adopted  with 
success.  Supernumerary  toes, 
if  in  the  way,  must  be  re- 
moved, and  I  have  had  occa- 
sion to  remove  several,  gener- 
ally an  extra  big  toe  attached 
at,  or  near,  the  inner  side  of 
the  metatarso-phalangeal  joint. 
There  is  no  fear  even  if  there 
be    a    common    joint  cavity 

opened.  Two  conjoined  toes  fused  into  one  joint,  usually 
produce  no  symptoms  calling  for  operation. 

Deficient  or  Excessive  Development.  —  These, 
though  fairly  common  in  orthopaedic  practice,  need  not 
occupy  our  space,  except  to  say  that  the  cardinal  rule  is  to 
interfere  as  little  as  possible  with  the  foot,  unless  absolutely 
necessary.  Overgrowth  of  one  or  more  toes,  if  forming  a 
great  deformity,  or  causing  serious  inconvenience,  may  be 
treated  by  amputation. 

Y    2 


Fig.  154. — Defective  first  and  fourth 
toes,  and  webbing  of  second  and  third, 
of  right  foot  in  a  boy.  The  left  hand 
was  deformed  and  is  represented  in 
the  next  section. 


324 


BODILY    DEFORMITIES. 


Bunions,  Corns,  and  Ganglions. — Though  these  are 
deformities,  and  also  serious  inconveniences  to  progression, 
and  frequently  come  under  the  care  of  the  orthopaedic 
surgeon,  I  need  not  occupy  time  and  space  by  entering 
into  their  pathology  and  treatment,  which,  for  practical 
purposes,  are  sufficiently  described  in  the  various  surgical 
text-books. 

In-turned  Toes. — This  is  a  condition  in  which  one  or 
both  feet  are   directed   inwards  in  walking,  and  in  some 


Figs.  155  and  156.— Right  equino-valgus  and  deformed  toes,  and  left  equino-varus 
and  supernumerary  clubbed  and  deformed  toes  from  the  encephalocele  case. 

cases  there  is  not  complete  plantar  contact  in  progression, 
as  the  inner  part  of  the  sole  is  raised  and  the  weight  borne 
on  the  outer  two-thirds  of  the  sole.  The  affection  to  which 
I  now  allude  has  nothing  to  do  with  the  early  walk  of  a 
cured,  or  of  a  slight  varus,  though  it  may  be,  in  some  in- 
stances, a  premonitory  sign  of  an  incipient  acquired  varus 
of  nervous  origin.  Subjects  of  this  affection  are  termed 
duck-footed. 

Causes. — In  many  cases  it  appears  to  be  due  to  persis- 
tence in  a  bad  habit  of  .  walking,  in  others,  it  is  due  to 
corns,  or  follows  on  a  bad  sprain,  and  in  others,  it  is  depen- 


EXTENSION    OF   THE   TOES.  325 

dent  on   an    incipient,  or  is   the   result    of  a   confirmed, 
paralysis. 

Treatment. — The  nervous  cases  must  be  dealt  with 
according  to  the  stage  of  the  disease,  and  the  state  of  the 
parts.  Those  due  to  injury,  or  corns,  usually  disappear  on 
the  cure  of  the  malady  producing  them,  and  are  but 
temporal*}'  symptoms.  Those  due  to  habit,  are  best  dealt 
with  by  making  the  patient  wear  an  apparatus,  which  con- 
sists of  a  pelvic  band  with  outside  irons.  The  band  is  in 
two  segments,  and  thus  permits,  by  means  of  straps  attached 
thereto,  of  everting  the  feet. 


326  BODILY   DEFORMITIES. 


PART    IV. 

DEFORMITIES    OF   THE   UPPER   LIMB. 


CHAPTER   XX. 

CLUB-HAND. 


Definition.— Club-hand  is  a  more  or  less  permanent 
deviation  of  the  hand  at  the  wrist,  in  flexion,  extension, 
abduction,  or  adduction,  or  in  one  of  the  intermediate  posi- 
tions. 

Synonyms.— German,  Klumphand ;  French,  Main  bote. 

Varieties.— The  term  club-hand  has  only  been  applied 
to  these  deformities  during  the  present  century,  and  they 
were  first  named  after  the  corresponding  deviations  in  the 
feet,  and  divided  into  varus,  equinus,  &c. ;  but  a  more  ratio- 
nal nomenclature  succeeded  this,  and  consists  in  naming 
the  distortion  according  to  the  physiological  position  of  the 
displaced  hand.  Thus,  if  it  be  in  flexion,  it  is  termed 
palmar  club-hand  ;  if  in  extension,  dorsal ;  if  in  abduction, 
ulnar  or  cubital ;  if  in  adduction,  radial ;  and  when  the 
hand  is  in  intermediate  positions  it  is  termed  radio-palmar, 
cubito-pahnar,  dorso-radial,  dor  so-cubital,  &c.  This  de- 
formity may  be  congenital  or  acquired,  and  may  be  single 
or  double. 


CONGENITAL    CLUB-HAND.  327 


CONGENITAL    CLUB-HAND. 


As  a  deformity  occurring  by  itself  it  is  rare,  very  much 
rarer  than  club-foot,  but  at  the  Royal  Orthopaedic  Hospital 
about  three  cases  of  the  deformity — generally  associated 
with  some  other  malformation — are  presented  annually.  It 
need  only  be  mentioned  that  this  distortion  is  not  infre- 
quently met  with  in  monsters,  but  these  need  not 
detain  us. 

Causes.— Similar  serological  reasons  to  those  adopted 
in  congenital  club-foot,  and  other  limb  deviations,  are 
applied  here,  viz.,  malposition  and  pressure  in  utero,  and 
the  ligamentous,  muscular,  nervous  and  osseous  theories 
are  brought  to  bear ;  but  in  this  deformity,  there  is  frequently, 
paralysis  of  some  of  the  muscles,  as  well  as  deficiency  of 
some  of  them  in  whole  or  part,  and  also  changes  or  absence 
of  some  of  the  osseous  structures,  whereas  in  ordinary  club- 
foot paralysis  is  not  usually  present,  and  absence  of  bony 
structures  is  very  rare.  So  far  as  these  cases  have  been 
submitted  to  examination,  it  appears,  that  though  para- 
lysis, and  in  other  cases,  shortening  of  some  muscles  is 
present,  yet  this  does  not  entirely  confirm  the  nervous 
origin  of  the  deformity,  because  these  changes  may  be 
secondary.  The  osseous  theory,  which  imputes  club-hand 
to  a  deficient  development,  or  original  imperfection  of  the 
bones,  appears  more  probable,  from  the  fact  that,  in  many 
cases,  there  is  atrophy  or  absence  of  some  of  the  bones, 
especially  of  the  radius,  outer  part  of  the  carpus,  first 
metacarpal,  and  thumb. 

Pathological  Anatomy.— There  are  three  chief  groups, 
or  varieties  of  this  deformity,  viz.,  i.  In  which  some  of  the 
bones  of  the  forearm,  wrist,  and  hand,  are  incomplete  and 
malformed,  and  this  is  the  commonest  form ;  2.  In  which 


32S 


BODILY    DEFORMITIES. 


the  bones  are  complete,  but  malformed  ;  and  3.  In  which 
the  bones  are  present  and  well-formed.  In  the  first  variety 
there  is  more  or  less  absence  of  the  radius,  and  the  thumb 
is  often  absent.  The  ulna  may  be  large  and  strong,  forming 
a  projection  at  the  inner  side  of  the  wrist,  or  it  may  be 
short,  thick,  and  curved  back  and  inwards.  The  change 
most  commonly  met  with  is  more  or  less  absence  of  the 


Fig.  157. — Double  congenital  club  hands  and  feet  occurring  in  the  same  infant. 


radius,  with  or  without  bony  deficiency,  or  deformity,  of  the 
carpus,  metacarpus,  and  phalanges. 

Malgaigne  (Lecons  d'Orthopsedie)  describes  three  pre- 
parations in  the  Musee  Dupuytren.  In  the  slight  case,  the 
radius  was  present ;  in  the  second,  there  was  almost  complete 
absence  of  the  radius,  but  the  thumb  was  present ;  and  in 
the  third,  the  radius  and  thumb  were  absent.  The 
articular  surface  and  lower  part  of  the  shaft  of  the  radius 
are  most  often  wanting,  sometimes  some  of  the  carpal,  or 
metacarpal  bones — especially  the  first  and  its  corresponding 


CONGENITAL    CLUB-HAND.  329 

phalanges — i.e.,  the  thumb,  are  absent.  There  is  commonly 
some  distortion  of  the  wrist-joint,  and  the  ulna  joins,  or 
articulates  with  it. 

The  muscles  in  the  first  variety  are  absent  in  part,  but  in 
others  they  may  be  normal  as  to  number,  but  they  are 
bound  down  in  a  peculiar  and  constricted  way  by  a  strong 
deep  fascia,  and  some  of  their  tendons  are  deficient,  or 
unusually  airanged.  In  the  other  forms,  especially  in  the 
simplest,  the  te?idons  are  found  contracted  on  the  deformed 


Fig.  158. — Radio-palmar  club-hand,  thumb  absent. 

border  of  the  limb.  Ligamentous  changes,  in  the  severe 
forms,  correspond  to  the  articular,  in  position  and  extent. 

The  vessels  and  nerves  are  often  altered.  The  radial 
artery  is  frequently  absent,  and  on  attempting  to  extend  the 
hand  it  becomes  blanched.  The  ulnar  artery  is  enlarged, 
so  that  while  the  superficial  palmar  arch  is  fairly  complete, 
the  deep  one  may  be  more  or  less  deficient.  The  median 
and  ulnar  nerves  are  often  coalesced,  forming  a  single  trunk 
down  the  front  of  the  forearm.  These  structures  will  be 
displaced  in  accordance  with  the  deformity. 

Classification,  Nomenclature,  and  Symptoms.— 
Though   these  deformities    have    been  compared    to  the 


3$0  BODILY    DEFORMITIES. 

different  kinds  of  club-foot,  they  do  not  in  reality  resemble 
them,  but  rather  those  rare  deficiencies  and  distortions  of 
the  lower  limb,  several  of  which  I  have  seen,  and  two  of 
them  are  represented  in  the  chapter  on  deformities  of  the 
foot.  The  simple  or  pure  forms — radial,  ulnar,  &c, — are 
very  uncommon,  but  the  composite  or  compound  forms  are 
more  frequently  met  with  in  a  large  orthopaedic  experience. 
In  this  respect  it  resembles  club-foot. 

The  radio-palmar  is  the  commonest  form,  the  cubito- 
palmar — which  is  its  opposite — is  much  rarer.  In  the 
former,  the  thumb  is  often  absent,  and  the  hand  forms  an 


Fig.  159— Left  radio-palmar  club-hand.    The  lower  part  of  radius  and  thumb  were 

absent. 


angle,  open  externally  or  antero-externally,  with  the  radial 
border  of  the  forearm,  and  sometimes  the  outer  border  of 
the  hand  touches  that  of  the  forearm,  or  even  of  the  arm. 
The  lower  end  of  the  ulna  projects  at  the  lower  and  inner 
side  of  the  forearm,  and  its  styloid  process  is  readily  felt. 

The  cubito-palmar  presents  the  opposite  deformity,  and 
the  above  description  reversed  will  fairly  well  represent  its 
appearance. 

The  palmar  is  one  of  the  commonest  of  the  simple 
forms,  and  in  it  the  hand  is  flexed,  and  the  fingers  and 
palm  turned  towards  the  anterior  or  flexor  surface  of  the 
forearm.     The  projection  at  the  wrist  on  the  dorsal  surface 


CONGENITAL    CLUB-HAND. 


331 


is  formed  either  by  the  lower  ends  of  the  radius  and  ulna, 
or  by  the  carpal  bones.  This  variety  is  oftenest  combined 
with  a  radial,  and  then  with  an  ulnar  deviation. 

The  dorsal  form,  whether  pure  or  complex,  is  very  rare, 
and  the  reverse  of  the  palmar  description  will  suffice  for 
its  portrayal. 

The  following  summary  will  make  these  deformities  more 
readily  understood. 

The  simple  forms,  such  as  the  radial,  ulnar,  palmar,  and 
dorsal,  are  rare.     Of  these,  the  radial  and  palmar  are  the 


Fig.  160. — Cubito-palmar  club-hand. 
Not  a  severe  case.  . 


commonest,  then  the  ulnar,  and  last  the  dorsal.  In  the 
radial  the  hand  is  abducted  and  its  radial  border  turned 
towards  the  external  border  of  the  forearm.  In  the  cubital 
the  hand  is  adducted  and  its  inner  border  is  towards  the 
ulnar  side  of  the  forearm.  In  the  dorsal  the  hand  is 
extended  and  bent  towards  the  extensor  aspect  of  the  fore- 
arm.' In  the  palmar  the  hand  is  flexed  and  turned  to  the 
flexor  aspect  of  the  forearm. 

The  compound  forms  are  commoner,   and   of    these  the 
radio-palmar  occurs  most  frequently,  then  the  cubito-palmar. 


S32  BODILY    DEFORMITIES. 

The  dorsal  forms,  whether  radial  or  ulnar,  are  the  rarest.  In 
the  pure  dorsal  the  hand  is  extended  and  bent  towards  the 
posterior  or  extensor  surface  of  the  forearm,  and  in  severe 
cases  may  touch  it.  This  and  its  composite  forms  are 
very  rare.  Though  any  of  these  forms  may  occur  of 
themselves,  they  are  most  commonly  associated  with 
deformities  in  other  parts  of  the  trunk,  or  in  the  lower 
limbs. 

In  the  course  of  a  large  orthopaedic  and  general  ex- 
perience I  have  seen  instances  of  most  of  these  forms 
and  had  drawings  taken  of  them  ;  and  some  of  these,  in  a 
reduced  form,  illustrate  the  text. 

Treatment. — This  will  vary  according  to  the  nature  of 
the  case,  and  consists,  in  those  cases  that  admit  of  it,  in 
tenotomy  of  any  tense  tendons,  and  the  use  of  instruments 
and  manipulations.  In  simple  cases,  where  one  or  more 
tendons  have  clearly  been  tense,  I  have  succeeded  in  correct- 
ing the  deformity  by  tenotomy,  and  the  subsequent  applica- 
tion of  a  properly  constructed  instrument,  and  the  use  of 
ordinary  orthopaedic  means,  such  as  those  adopted  in  the 
after  treatment  of  club-foot,  viz.,  frictions,  massage,  &c. 
In  two  severe  cases  much  benefit  was  derived  from  pro- 
perly adjusted  machines,  combined  with  massage,  &c. 
Mr.  Schramm  made  a  very  efficient  and  light  apparatus 
suitable  for  these  cases.  In  the  worst  forms  nothing  can 
be  done  except  amputation,  but  as  there  is  frequently  much 
use  in  the  deformed  limb,  this  measure  should  be  avoided, 
in  most  cases. 

Tenotomy.— Division  of  the  tendons  of  muscles  mov- 
ing the  hand  is  a  thoroughly  satisfactory  operation  as  far 
as  their  reunion  is  concerned,  but  opinions  differ  as  regards 
the  safety  of  dividing  the  tendons  of  the  flexors  or  ex- 
tensors of  the  fingers,  as  in  some  the  operation  has  been 
followed  by  non-union  and  consequent  loss  of  mobility  ; 


CONGENITAL    CLUB-HAND.  333 

but  if  the  place  of  operation  be  properly  selected,  and  the 
after-treatment  be  properly  conducted,  there  is  no  fear — in 
cases  suitable  for  the  operation — of  non-union  or  the  pro- 
duction of  the  opposite  deformity.  After  tenotomy,  the 
deformed  parts  must  be  replaced  in  their  original  position 
for  three  to  five  days,  and  then  carefully  and  gradually  ex- 
tended, and  when  extension  is  complete,  massage  and 
the  use  of  a  properly  constructed  instrument  for  a  few 
months,  will  suffice  to  cure  the  deformity. 

In  radial  club-hand  the  extensors  of  the  wrist  on  the 
radial  side,  one  or  both,  may  require  division,  and  in 
severer  forms  the  long  and  short  extensors  of  the  thumb 
may  have  to  be  divided. 

In  the  ulnar  form,  the  extensor  carpi  ulnaris  may  need 
division. 

In  the  palmar  deformity,  the  palmaris  longus  and  flexors 
carpi  radialis  and  ulnaris  may  need  section.  In  dividing  the 
two  latter  muscles  care  must  be  taken  to  avoid  wounding 
the  radial  artery,  which  is  to  the  outer  side  of  the  tendon 
of  the  flexor  carpi  radialis,  but,  in  congenital  cases,  this  is 
usually  absent ;  and  the  ulnar  artery  and  nerve,  which  is 
also  on  the  outer  side,  and  somewhat  beneath  the  tendon 
of  the  flexor  carpi  radialis  must  not  be  divided.  The 
median  nerve  lies  deeply,  between  the  two  portions  of  the 
flexor  sublimis  and  is  not  in  danger,  and  the  radial  nerve 
has  become  cutaneous,  so  if  it  were  injured,  only  temporary 
anaesthesia  would  probably  result.  In  the  worst  cases,  it 
may  be  necessary  to  divide  the  tendons  of  the  superficial 
and  deep  flexors.  This  must  be  done  on  the  fingers,  as 
described  in  the  chapter  on  contracted  fingers. 

In  dorsal  club-hand,  if  the  two  radial  extensors  and  the 
ulnar  extensor,  be  tense  and  resist  reposition,  they  will  need 
tenotomy,  and  if  this  do  not  suffice,  the  extensor  communis 
must  be  divided. 


334  E0D1LY    DEFORMITIES. 

In  mixed  eases,  those  tendons  which  are  tense  on  attempt- 
ing to  reduce  the  deformity,  must  be  divided,  and  will  vary 
with  the  nature  of  the  case. 

It  must  be  recollected,  that  in  ordinary  congenital  club- 
hand the  tendons  are  not,  as  a  rule,  primarily  contracted, 
but  may  become  so  secondarily.  In  the  acquired  forms, 
presently  to  be  described,  they  often  need  division,  being 
in  a  retracted  state. 

ACQUIRED    CLUB-KAND. 

This  distortion  is  rarely  so  well  marked  as  in  typical  cases 
of  congenital  club-hand,  but  some  of  those  due  to  nerve 
changes  which  I  have  seen,  have  been  of  a  severe  character. 
Duchenne  and  other  neurologists  figure  some  bad  forms  of 
club-hand,  and  all  physicians  attached  to  hospitals  for  the 
treatment  of  nerve  diseases,  must  have  seen  several  well- 
marked  cases. 

Causes.— Injuries  such  as  severe  sprains,  fractures  near 
the  wrist,  or  dislocations,  may  lead  to  permanent  displace- 
ment and  retraction  of  the  tendinous  and  ligamentous 
structures  around  the  joints,  or  primary  or  secondary  inflam- 
mations, with  retraction  and  adhesions  of  the  tendons  to 
their  sheaths,  may  produce  varying  degrees  of  deformity 
more  or  less  simulating  club-hand,  as  may  also  contracted 
cicatrices  from  severe  burns,  or  disease  of  the  carpal  joints. 
Central  nervous  lesions  producing  irritation  and  contraction, 
or  loss  of  function  and  paralysis,  are  commoner  causes. 

Symptoms  and  Diagnosis.— The  history  of  the  case 
will  ordinarily  suffice  to  make  these  matters  clear.  In  cases 
due  to  nerve  lesions,  there  will  be  no  paralysis  in  the 
irritative  stage,  but  contraction  and  subsequent  retraction 
of  the  affected  muscles ;  and  in  paralytic  cases,  the  wasted 
condition  of  the  limb,  the  red  or  purple  colour  of  the  skin, 


ACQUIRED    CLUB-HAND.  335 

and  the  coldness  of  the  limb,  with  evident  loss  of  voluntary 
motion,  will  make  the  diagnosis  clear. 

Prognosis. — In  most  cases  that  I  have  seen,  this  is 
favourable.  That  is  to  say,  with  the  exclusion  of  the 
nervous  cases,  and  especially  the  paralytic,  a  very  useful 
member  may  be  promised  the  patient ;  and  even  the  paralytic 
cases,  if  treated  before  there  is  much  wasting  of  muscular 
tissue,  and  while  there  is  yet  time  to  do  something  to 
check  the  increase  of  the  nerve  mischief,  may  be  a  good 
deal  benefited.  Some  cases  due  to  inflammatory  mischief 
along  the  sheaths  of  the  tendons,  require  much  patient 
perseverance  on  the  part  of  patient  and  surgeon. 

Treatment. — This  must  vary  according  to  the  nature 
of  the  case.  If  cicatricial  or  ancbylutic,  the  treatment 
must  be  conducted  according  to  the  directions  given  in 
the  chapters  on  those  subjects.  If  contraction  of  muscles 
be  present,  these  may  be  gradually  stretched  by  splints,  or 
instruments,  or  forcibly  straightened  under  anaesthesia,  and 
subsequent  frictions,  &c,  adopted.  Descending  continuous 
electrical  currents  may  be  of  use.  If  retraction  of  muscles 
be  existing,  their  tendons  must  be  divided.  Paralytic  cases 
must  receive  a  suitable  internal  as  well  as  local  treatment, 
the  latter  consisting  of  massage,  galvanism,  electricity,  &c. ; 
but  if  these  fail,  and  much  and  troublesome  deformity  exist, 
tenotomy,  with  very  gradual  restoration  of  the  deformed 
parts,  must  be  resorted  to.  Subsequent  frictions  and 
manipulations  will  be  necessary  for  several  months  or 
longer,  and  a  suitable  light  instrument,  with  elastic  traction 
in  the  requisite  direction,  must  be  worn  during  the  whole 
time.  I  have  treated  not  a  few  cases  which  were  cured  as 
regards  the  deformity,  and  some  of  them  had  serviceable 
hands  when  last  seen,  so  that  I  am  sure  it  is  a  great  mistake 
to  tell  all  these  patients  that  they  are  incurable. 


336  BODILY    DEFORMITIES. 


CHAPTER   XXI. 

DEFORMITIES    OF    THE    FINGERS. 

These  commonly  occur  in  the  direction  of  flexion, 
though  the  fingers  may  deviate  from  each  other  laterally, 
or  be  hyperextended,  or  displaced  backwards.  Various 
degrees  of  these  deformities  are  met  with  in  a  large  ortho- 
paedic experience,  and  fortunately  the  large  majority  are 
amenable  to  appropriate  surgical  treatment.  I  will  first 
treat  of  flexed  fingers,  and  then  of  the  abnormalities  known 
as  polydactylism,  syndactylism,  &c. 

Varieties. — They  may  be  arranged  serologically  into 
muscular,  aponeurotic,  osseous,  cicatricial,  articular,  tuber- 
cular, and  nervous.  They  may  also  be  congenital  or 
acquired,  and  traumatic  or  pathological.  The  nervous, 
cicatricial,  tubercular,  and  aponeurotic  are  commonest,  if 
we  except  rheumatism  and  gout,  which  do  not  usually  lead 
to  exactly  similar  deformities,  and  may  be  classed  among 
the  articular. 

Causes. — These  have  been  stated,  generally,  in  the  pre- 
vious paragraph,  but  a  little  more  detail  is  desirable,  as 
furnishing  valuable  indications  for  treatment.  A  primary 
myositis,  leading  to  degeneration  of  the  affected  muscles, 
is  rare ;  the  osseous  and  articular  may  be  due  to  injuries, 
such  as  fractures  and  dislocations,  or  to  ostitis,  or  joint 
disease.  Severe  burns  are  the  most  common  of  the  cica- 
tricial cases ;   the  tubercular  forms  are    due  to    dactylitis 


CONGENITAL    DEFORMITIES.  337 

deformans,  and  specially  occur  in  strumous  children  ;  and  the 
rheumatic  and  gouty  forms  are  too  well  known  to  need 
description  here.  The  congenital  cases  may  be  caused  by 
defective  development  and  improper  conformation  of  the 
digital  structures,  or  may  be  due  to  nerve  irritation,  or  con- 
traction of  the  palmar  fascia.  I  have  seen  a  case  in  a  baby 
which  was  attributed  by  the  mother  to  teething  convulsions. 
Of  all  these  forms  the  nervous,  cicatricial,  and  aponeurotic 
are  most  frequently  met  with  in  hospital  orthopedic  practice, 
and  will  be  chiefly  dealt  with.  The  nervous  cases  may  be 
seen  when  there  is  nerve  irritation,  and  then  there  will  be 
contraction  of  the  affected  muscles,  and  subsequent  re- 
traction.    There  are  also  the  numerous  paralytic  cases. 

The  congenital  cases  consist  in  webbing,  or  union  of  the 
fingers  \  in  excessive  development,  i.e.,  supernumerary 
digits  ;  defective  development,  i.e.,  absence  of  them,  and 
part  of  the  hand;  hypertrophy  and  contractions,  i.e.,  flexed 
fingers.  The  acquired  forms  are  most  commonly  due  to 
nerve  lesions,  or  to  injury  of  the  muscles,  tendons  and 
their  sheaths.  There  is  also  the  affection  of  the  palmar 
fascia,  known  as  Dupuytren's  contraction.  A  peculiar  con- 
dition, which  in  this  work  is  for  the  first  time  described  in 
this  country,  I  have  termed  jerk  or  spring  finger.  As  most 
of  these  conditions  are  amenable  to  surgical  treatment,  I 
shall  deal  with  them  separately,  first  considering  the  con- 
genital forms. 

CONGENITAL    DEFORMITIES. 

Supernumerary  Fingers,  i.e.,  Polydaetylism,  is  in 
orthopaedic  experience,  a  not  very  uncommon  occurrence. 
It  occurs  in  three  chief  forms.  1.  The  supplemental  digit  is 
rudimentary,  and  is  usually  attached  by  a  pedicle  to  one  of 
the  fingers,  generally  on  the  outer  or  inner  side  of  the 
hand,  or  to  the  distal  ends  of   the  metacarpal  bones.     It 


333 


BODILY    DEFORMITIES. 


may  contain  a  little  cartilage.  2.  The  extra  digit,  fully 
formed,  may  articulate  with  the  joint  ends  of  one  of  the 
fingers,  or  with  one  of  their  lateral  surfaces,  or  with  a  metsi- 
carpal  bone.  3.  There  may  be  a  united  double-finger,  i.e., 
the  extra  complete  digit  may  be  joined  to  the  whole  length 
of  its  neighbour,  and  may  possess,  or  not,  a  separate 
metatarsal  bone.  If  this  be  absent  it  articulates  conjointly 
with  its  neighbour.  In  such  a  case,  there  is  commonly  but 
one  capsular  ligament,  and  the  joint  cavity  belongs  to  both 
fingers. 


Figs.  162  and  163. — Supernumerary  thumb  (to  left)  ;  extra  index  (to  right.) 


Treatment. — Those  of  the  first  order  should  be  re- 
moved, as  also  those  of  the  second,  if  they  are  useless 
incumbrances  ;  but  in  the  third  variety,  if  the  deformity  be 
unsightly  as  well  as  useless,  amputation  is  the  best  resource. 
In  the  case  of  the  extra  finger  having  a  common  articular 
cavity  with  its  neighbour,  it  has  been  recommended  not  to 
remove  it,  because  of  opening  the  joint,  or  to  remove  it 
at  some  distance  from  this  ;  but  the  plan  appears  to  me 
bad,  for  if  the  finger  be  removed  at  all  it  must  be  removed 
entire,  and  to  leave  a  projecting  stump  is  often  more  unsightly 
and  inconvenient  than  to  remove  the  whole  digit.     More- 


CONGENITAL    DEFORMITIES.  339 

over,  in  many  instances,  I  have  removed  the  extra  finger 
or  toe  at  the  joint,  and  never  have  seen  any  bad  results. 

Syndactylism  consists  in  the  lateral  union  of  fingers  by 
means  of  soft  parts,  or  it  may  be  of  the  third  variety  spoken 
of  in  the  previous  paragraph.  There  are  three  forms,  i. 
The  membranous.  2.  The  fleshy.  3.  The  osseous,  or 
rather,  cartilaginous.  The  first  is  the  commonest.  If  folds 
of  skin  be  the  uniting  medium,  they  are  then  known  under 
the  name  of   webbed   fingers.     The  inner  fingers  are,   in 


Fig.  164. — Bifurcated  or  double  hand  ;  no  thumb. 


my  experience,  more  commonly  united,  but  any  of  them 
may  be  joined,  though  it  is  rare  to  find  a  thumb  united  to  the 
index.  The  web  may  be  partial  or  complete,  in  the  former,  it 
only  extends  along  the  first  interphalangeal  joint,  or  perhaps 
a  little  beyond  ;  in  the  latter,  the  fingers  are  united  to  near 
their  tips.  The  web  may  be  short,  i.e.,  the  fingers  are 
closely  united,  or  it  may  be  loose,  allowing  of  a  certain 
amount  of  separation.  In  the  latter  case,  the  fingers  are  of 
greater  use,  but  as  the  deformity  is  unsightly,  treatment  is 
called  for. 

z  2 


34o 


BODILY    DEFORMITIES. 


WQ 


The  acquired  cases  are  those  of  cicatricial  webbing,  which 
are  not  uncommonly  caused  by  burns,  especially  in  children, 
the  treatment  is  somewhat  the  same.  Occasionally,  the  web 
is  thick  and  fleshy,  and  sometimes  the  union  is  bony.  The 
fold  of  skin  forming  the  web,  has  its  base,  which  is  usually 
concave,  towards  the  free  ends  of  the  fingers,  and  its  apex 
at  the  interdigital  space.  A  slight  amount  of  webbing,  i.e., 
an  increase  in  the  interdigital  fold,  is  not  very  uncommon, 
and  the  subject  appears  to  have  short  fingers. 

Cause. — The  study  of  development  has  explained  the 
occurrence   of    this   deformity.      The 
rudiment  of  the    hand    consists    in   a 
rounded  flap,  with  tubercles  at  its  free 
end — the   incipient  fingers — separated 
by  four  grooves,  but  this  separation  is 
more   apparent   than  real,    for,  in  the 
embryo,  the  digits  tend  to  group  them- 
selves two  by  two,   and  especially  do 
the   ring   and  little  fingers  affect  this 
arrangement,    hence    the    comparative 
commonness    of    their    union.      The 
arrest  of  the   process   which  deepens 
the  grooves  and  separates  the  fingers, 
is  the  cause  of  this  deformity. 
Treatment. — Formerly,  it  was  the  custom   to  slit  the 
web  and  to  prevent  reunion  by  strips  of  wet  or  oiled  lint, 
pushed  firmly  down  between  the  heads  of  the  metacarpal 
bones,  but  there  was  such  a  tendency  either  to  reunion,  or 
to  cicatricial  contraction,  reproducing  the  web,   that  other 
means   had   to   be   devised.     This   led   to   the   following 
plan  : — 

Operation  by  a  Permanent  Opening  at  the  Base 
of  the  Web.— A  silver  or  gold  ring  with  a  sharp  point  is 
passed  through  the  base  of  the  web,  and  the  other  end  of 


Fig.    165.  —  Stunted    and 
webbed  hand. 


CONGENITAL    DEFORMITIES.  34 1 

the  ring  being  hollow,  the  sharp  point  is  fitted  into  it,  and 
the  ring  left  in  place.  It  must  be  shifted  from  time  to 
time  until  cicatrization  has  occurred  around  it,  then  the  web 
is  slit  down  with  a  scalpel,  and  the  fingers  kept  a.part  by 
oiled  lint,  well  forced  down  into  the  base  of  the  web,  until 
healing  has  taken  place. 

The  same  object  may  be  effected  with  the  use  of  a  silver 
rod,  or  bracket.  This  consists  of  a  screw  at  one  end,  on  to 
which  is  fixed  a  sharp  point.  This  is  made  to  transfix  the 
web  at  its  base  ;  the  sharp  point  is  then  detached,  and  a 
nut  is  then  screwed  on  so  as  to  retain  the  apparatus  in 
position  until  cicatrization  has  occurred.  The  remainder  of 
the  web  is  then  treated  as  already  described. 

The  third  plan  is  by  elastic  traction.  An  india-rubber 
cord  is  passed  through  the  base  of  the  web  by  means  of  a 
trochar  and  canula.  This  passes  along  the  palm  and 
dorsum,  and  is  attached  to  a  circlet  at  the  wrist,  and  by 
keeping  up  occasional  gentle  traction,  it  will,  by  its  tension, 
make  a  good  opening  at  the  base  of  the  web,  and  when 
healing  has  occurred  around  it,  the  web  may  be  dealt  with 
as  already  described.  Some  surgeons,  not  satisfied  with  the 
results  of  these  plans,  have  devised  plastic  operations,  of 
which  there  are  several ;  but  the  three  which  I  shall 
describe,  appear  to  me  to  be  the  best.  I  have  tried  them 
all,  and  can  speak  well  of  them. 

Didot's  operation. — The  accompanying  illustrations, 
which  represent  the  middle  and  ring  fingers,  will  sufficiently 
explain  this  method.  An  incision  is  made  along  the 
middle  of  the  palmar  surface  of  one  finger,  and  is  joined, 
at  each  end,  by  short  transverse  cuts,  so  as  to  form  a  flap. 
A  similar  proceeding  is  executed  on  the  dorsum  of  the  other 
finger,  and  two  flaps  are  thus  formed.  The  palmar  flap  of 
one  finger  fits  over  the  dorsal  surface  of  its  neighbour. 
The  transverse  sections  of  the  fingers  are  shown,  and  the 


342 


BODILY    DEFORMITIES. 


figure  to  the  left  shows  the  line  of  the  incisions,  the  middle 
figure  shows  the  flaps  separated,  and  the  right  hand  one 
represents  the  flaps  in  position.  It  is  well,  as  Annandale 
has  pointed  out,  to  avoid  making  the  flaps  broad,  so  as  not 
to  encroach  unnecessarily  on  the  palmar  and  dorsal  surfaces 
of  the  fingers.     The  inter-digital  cleft  must  be  carefully 


Figs.  166,  167,  168,  and  169. — Diagram  of  the  incision  and  flaps  in  Didot's  opera- 
tion.    The  dotted  line  shows  the  limits  of  the  adjoining  fingers. 


watched  to  prevent  recontraction,  which  always  commences 
there,  and  is  a  drawback  in  this  otherwise  excellent  plan. 

Zeller's  operation. — Two  incisions,  A  and  B,  meeting 
at  C  on  the  dorsal  aspect  of  the  web  and  fingers,  are  made, 
and  extend  from  the  metacarpo-phalangeal  to  the  first 
inter-phalangeal  joints.  This  triangular  flap  is  reflected 
towards  its  base,  and  the  remainder  of  the  web  is  divided 
along  the  line  C,  D.     E  and  G  represent  the  reflected  flap 


CONGENITAL    DEFORMITIES. 


343 


and  the  raw  surfaces  of  the  fingers  after  division  of  the 
web.  The  fingers  being  held  well  apart,  the  flap  is  fixed  to 
the  palmar  surface  and  between  the  cleft,  and  obviates  the 
tendency  to  contraction. 

Dece's  operation. — When  the  web  is  large  he  pinches 
up  a  fold  of  skin  near  its  base  and  dissects  it  towards  the 
commissure,  and  keeps  the  fingers  apart.  On  cicatrising, 
this  tongue  of  skin  retracts  and  gradually  forms  a  new 
commissure. 


Fig.  170. — Diagram  of  the  incisions  and  flaps  in  Zeller's  operation. 


Norton's  operation. — In  the  British  Medical  Journal, 
August,  1 88 1,  Mr.  Norton  has  described  an  operation 
which  is  a  decided  improvement  on  that  of  Dece's.  Small 
rounded  anterior  and  posterior  flaps  are  made  at  the  clefts, 
with  their  bases  at  the  heads  of  the  metacarpal  bones. 
The  web  is  then  divided  and  the  flaps  joined  at  their 
apices.  The  following  points  should  be  attended  to : — 
1.  The  flaps  should  be  thick,  so  that  their  vascular  supply 
be  good;  2.  They  should  be  rather  narrow  to  prevent 
bulging ;  3.  The  tissues  between  the  knuckles  should  be 


344 


BODILY    DEFORMITIES. 


cut  back,  or  removed,  to  let  the  flaps  meet  well ;  4.  The 
flaps  must  be  long  enough  to  prevent  tension ;  5.  Their 
apices  are  very  small  in  children,  and  require  a  small  needle, 
so  as  not  to  injure  their  vessels  ;  6.  The  position  of  the 
flaps  must  be  carefully  arranged,  so  that  the  new  web  may  be 


Fig.  171. — Diagrams  of  incisions  and  flaps  in  Norton's  operation. 

in  a  line  with  the  natural  one  ;  7.  The  fingers  should  be 
kept  apart  during  the  healing  process. 

Congenital  Deficiencies.— These  are  usually  of  two 
kinds,  numerical  deficiencies,  or  those  of  size.  In  the 
former,  one  or  more  fingers  may  be  absent,  with  or  without 
corresponding  absence  of  the  metacarpals.     In  the  latter, 


CONGENITAL   DEFORMITIES. 


345 


one  or  more  of  the  phalanges  may  be  wanting,  or  there  may 
be  the  condition  known  under  the  head  of  congenital 
amputations.  I  have  seen  several  varieties  of  these  defor- 
mities, but  only  rarely  has  any  treatment  been  likely  to  be 
of  use.  If  there  be  connections  between  the  deformed 
digits,  then,  in  some  cases,  operative  methods  will  be  of 
great  service.  If  there  be  contractions,  these  must  be  dealt 
with  according  to  the  cause  of  contraction.  If  an  imper- 
fectly developed  finger  be  useless,  or  in  the  way,  it  must  be 
removed. 

Congenital  Contractions 
are  rare.  They  may  be  due  to  de- 
fective development  in  the  bones, 
muscles,  or  fasciae,  or  to  nerve 
lesion,  and  must  be  dealt  with 
accordingly.  I  have  seen  but 
three  instances,  so  far  as  I  re- 
collect ;  two  of  these  were  much 
improved  by  oily  frictions,  man- 
ipulations, and  the  use  of  an 
extending  apparatus.  I  advised 
the  parents  to  bring  the  infants 
when  they  were  a  year  old,  but 

as  I  have  only  seen  one  of  them,  I  concluded  that  they 
thought  the  others  sufficiently  benefited,  or  that  they  had 
given  up  further  treatment,  or  had  applied  elsewhere.  In 
the  third  case,  in  which  the  little  finger  was  contracted, 
I  divided  a  tense  band  of  palmar  fascia  subcutaneously,  and 
applied  extension,  and  the  finger  very  shortly  after  assumed 
its  normal  position  and  use. 

Congenital  Hypertrophy.— This  may  affect  one  or 
more  digits,  or  may  involve  the  hand  or  even  the  whole 
limb.  The  increase  in  size  may  be  due  to  an  excessive 
development  of  all  the  tissues,  or  of  only  the  subcutaneous 


Fig.  172. — Defective  and  partly- 
webbed  fingers  of  left  hand  of  a 
boy  whose  right  foot  is  repre- 
sented in  the  last  section. 


346 


BODILY    DEFORMITIES. 


fatty  tissue.  Sometimes,  and  this  is  rare,  only  one,  or  more, 
of  the  phalangeal  articulations  is  increased  in  size.  The 
cause,  so  far  as  it  is  known,  is  ascribed  to  excessive 
nutrition,  or  excitement  of  the  part  during  development. 
A  woman,  aged  forty-nine,  the  subject  of  this  congenital 
condition,  has  been  for  some  time  an  out-patient  of  mine 
at  the  London  Hospital.  She  applied  on  account  of  rheu- 
matic arthritis  of  the  knees.  The  fingers,  and  especially  the 
middle  and  ring-fingers,  are  enormously  overgrown,  and  the 


Figs.   173  and  174. — Defective  and  deformed  fingers  from    the  encephalocele  case 
fisrured  in  the  last  section. 


former  somewhat  curved.     A  wax  model  of  her  hand  is  in 
the  London  Hospital  Museum. 

Treatment.— In  infants,  well  regulated  pressure  long 
continued  may  be  of  service,  but  when  this  is  removed  the 
growth  is  somewhat  apt  to  relapse.  Some  writers  are  for 
leaving  these  growths  alone,  because  congenital  overgrowths, 
and  even  tumours  of  innocent  character,  have  sometimes 
been  known  to  disappear;  but  in  the  case  just  alluded  to, 
the  fingers  increased  in  size  with  her  growth,  but  she 
declined  any  interference.  If  the  finger  or  fingers  be  in  the 
way,  and  they  are  always  unsightly,  amputation  seems  the 


CONGENITAL    DEFORMITIES. 


347 


only  radical  resource  ;  but  in  the  event  of  the  hand  or 
limb  being  affected,  ligature  of  the  main  artery  may  be 
tried. 

I  have  seen  several  well-marked  instances  of  hypertrophy, 
either  congenital,  or  occurring  during  childhood,  in  the  upper 
or  lower  limb ;  and  I  recollect 
a  case  which  occurred  at  the 
Royal  Orthopaedic  Hospital, 
under  the  late  Mr.  Daniel 
Hill,  in  which  he  tied  the  ex- 
ternal iliac  artery  with  cer- 
tainly temporary  benefit,  but 
I  do  not  know  the  ultimate 
result.  Some  of  these  cases 
are  of  the  nature  of  elephan- 
tiasis, and  probably  lymphatic 
in  origin. 

Congenital  Lateral  Deviation.— The  annexed  figure 
shows  a  case  of  this  rare  deformity  which  occurred  in  a  fine 
healthy  boy,  who  is  now  under  care,  wearing  an  instrument 
which  is  acting  efficiently  on  the  displacement. 


Fig.   175. — Congenital    lateral   devia- 
tion of  left  index. 


ACQUIRED    DIGITAL    DEFORMITIES. 

Causes. — These  may  be  the  result  of  injuries  affecting 
the  muscles,  tendinous  sheaths,  or  nerve  centres.  They 
may  also  be  due  to  contraction  after  burns,  but  there  are 
two  particular  forms  in  which  the  functions  of  the  fingers 
are  interfered  with,  which  deserve  a  somewhat  lengthened 
notice.  These  are  contraction  of  the  palmar  fascia  (Dupuy- 
tren's),  and  an  affection  which  I  shall  term  je?'k,  snap,  or 
spi'i?ig  finger.  The  deformities  due  to  athetosis  are,  as  far 
as  is  at  present  known,  of  a  temporary  character  ;  and  the 
clubbing  of  the  ungual  phalanges  in  myxcedema,  and  some 


348  BODILY    DEFORMITIES. 

lung  affections,  need  not  detain  us,  as  the  treatment  is  not 
specially  orthopaedic. 

Muscular  and  Nervo-Muscular  Affections—  In- 
juries resulting  in  division  of  the  muscles,  or  in  inflammation 
of  the  tendinous  sheaths,  may,  mechanically,  give  rise  to 
either  contraction  in  extension  or  flexion,  according  to  the 
muscles  affected.  Rheumatism,  gout,  and  syphilis,  may  all 
produce  finger  deformities,  either  through  affecting  the 
muscles  or  the  bones  and  articulations.  The  nervous  affec- 
tions may  be  due  to  disease  in  the  nerves,  or  in  the  nerve 
centres.    In  the  latter  there  is  flexion  of  the  fingers,  because 


Fig.  176.— Muscular  con-       Fig.  177.  —  Contracted  Fig.  178.— Contracted  exten- 
traction  of  fingers.  flexors  from  infantile  para-  sors. 

lysis. 

the  flexors  are  more  powerful  than  the  extensors.  In  lead- 
palsy  this  is  more  marked,  as  the  extensors  are  then  affected. 
The  deformity  due  to  paralysis  of  the  interossei  is  marked 
by  the  proximal  phalanx  being  extended  on  the  metacarpal, 
while  the  two  other  phalanges  are  flexed.  In  some  cases  of 
chronic  spinal  meningitis  the  fingers  and  the  thumb  are  a 
good  deal  flexed,  whereas  in  others  the  extensors  are  con- 
tracted. I  have  seen  well  marked  deformities  of  the  hand 
and  fingers  in  cases  of  infantile  paralysis,  and  also  from 
hysteria.  The  accompanying  figures  illustrate  some  of 
these. 


ACQUIRED    DIGITAL    DEFORMITIES. 


349 


Lateral  Deviation  of  Fingers.— The  accompanying 
figure  is  taken  from  a  young  man,  aged  twenty,  who  writes 
a  good  deal,  being  a  clerk.  He  comes  of  a  rheumatic  stock. 
His  hands  are  large  and  red,  and  their  circulation  feeble, 
and  the  last  phalanges  of  his  index  and  middle  fingers  are 
deviated  towards  the  thumb,  and  there  are  bony  growths  at 
the  bases  of  the  ungual  phalanges  on  their  ulnar  sides.  He 
is  improving  under  the  use  of  an  apparatus  which  keeps  the 
joints  in  their  proper  position ;  and  I  had  intended  in  this, 
as  in  the  case  of  the  little  boy  with  congenital  lateral  devia- 


Fig.  179.— Wasted  and 
deformed  hand  due  to 
chronic  spinal  meningitis. 


Fig  180. — Lateially  dis- 
placed left  index  and  mid. 
die  ungual  phalanges.  See 
text. 


tion,  to  divide  the  ligaments   should  the  instruments  not 
suffice  for  their  correction. 

Diagnosis.— The  history  of  the  case  will  generally  suffice 
to  distinguish  whether  the  disease  be  of  muscular  or  nervous 
origin,  and  the  condition  of  the  palm  will  serve  to  differ- 
entiate them  from  Dupuytren's  contraction.  If  flexion 
predominate,  we  must  endeavour  to  ascertain  whether  it  be 
due  to  the  superficial  or  deep  flexor.  In  the  former  case, 
the  distal  phalanx  can  be  extended,  though  flexed  on  the 
second.  If  both  flexors  be  affected,  their  tendons  will  be 
felt  to  be  stretched,  on  the  finger  being  put  in  extension. 
Anaesthesia  will  decide  as  to  whether  the  flexion  be  due  to 


35° 


BODILY    DEFORMITIES. 


contraction  or  retraction.  In  the  muscular  cases,  flexion 
will  be  combined  with  adduction  in  the  index,  ring,  and 
little  fingers.  I  have  lately  divided  the  tendon  of  the 
flexor  sublimis,  and  of  the  first  palmar  interosseous,  in  a 
contraction  following  an  inflamed  finger.  The  patient  was 
a  middle-aged  woman,  and  her  left  index  was  firmly  flexed, 
and  the  end  of  the  digit  was  across  the  middle  of  the 
palm.  There  was  intertrigo  of  the  digital  cleft.  I  divided 
the  flexor  tendon  just  distally  to  the 
palmo-digital  fold. 

Treatment.— This  must  depend 
upon  the  cause,  and  the  stage  of  the 
malady.  In  the  traumatic  cases,  if  it 
be  due  to  binding  down  of  the  muscles 
or  the  tendons  in  their  sheaths,  I  have 
known  an  incision  exposing  these,  and 
freeing  them  of  all  adhesions,  followed 
by  passive  motion,  to  be  of  great  ser- 
vice. If  nerves  have  been  divided 
they  may  be  cut  down  upon,  their 
ends  pared  and  brought  together  by 
stitches  in  the  neurilemma,  or  by  tying 
the  nerves  together  as  the  sheath  is 
apt  to  give  way.  I  have  operated 
on  a  few  cases,  and  have  seen  others 
submitted  to  a  like  procedure  with 
very  gratifying  results  as  regards  motion,  sensation,  and 
cure  of  the  deformity.  In  cases  due  to  central  nerve 
mischief,  all  irritation  and  spasm  must  have  passed  awray 
before  surgical  proceedings  can  be  adopted.  In  such  cases, 
stretching  of  the  affected  nerves  may  be  of  service,  but  if 
not,  tenotomy  of  the  affected  muscles,  and  careful  after 
treatment,  will  correct  the  deformity.  Electricity,  massage, 
&c,  should  first  be  tried  in  these  cases.     The  extensors 


Fig.  i8i.- — Apparatus  for 
elastic  correction  of  con- 
tracted fingers. 


ACQUIRED    DIGITAL    DEFORMITIES. 


;5i 


may  be  divided  at  the  wrist,  care  being  taken,  on  the  outer 
side,  of  the  radial  artery;  or  they  may  be  divided  on  the 
phalanges.     The  flexors  are  best  divided  as  follows  : — 

Tenotomy  of  the  Digital  Flexors. — When  these 
muscles  are  retracted,  they  may  either  be  forcibly  straight- 
ened during  anaesthesia,  or,  if  too  resisting  for  this  purpose, 
their  tendons  had  better  be  cut.  and  this  whether  the  retrac- 
tion be  due  to  nerve,  rheumatic,  gouty,  or  syphilitic  mis- 
chief. 

To  divide  the  Superficial  Flexor : — If  this  be  re- 
tracted independently  of  the  deep,  the  tenotome  should  be 


Fig.  182. — Mechanical  pen  for  writer's  paralysis. 


Fig.  183. — Gauntlet  for  the  same. 


introduced  about  a  quarter  of  an  inch  in  front  of  the  base 
of  the  second  phalanx,  on  its  palmar  aspect.  The  deep 
flexor  should  be  divided  opposite  the  base  of  the  ungual 
phalanx,  on  its  palmar  aspect.  At  these  spots  there  are 
processes  which  will  prevent  the  divided  tendons  separating 
too  far.  A  figure  of  these  will  be  found  in  my  Human 
Morphology.  The  subsequent  treatment  is  the  same  as  in 
other  cases  of  tenotomy. 

Writer's  or  Scrivener's  Palsy. — This  malady  consists 
in  an  irregular  spasmodic  action  of  some  of  the  hand 
muscles,  and  is  shown  on  attempting  to  write,  sew,  or  play 


352  BODILY    DEFORMITIES. 

the  piano,  or  in  any  complicated  manual  exercise.  It  is 
due  to  overwork  of  certain  groups  of  muscles,  and  is  met 
with  in  clerks,  telegraphists,  machinists,  etc.  Its  pathology 
needs  clearing  up,  but  its  symptoms,  in  many  cases,  re- 
semble those  of  other  spasmodic  affections,  i.e.,  spasmodic 
wry-neck,  etc. 

Treatment. — Medical  means  are  not  much  to  be  relied 
on,  but  the  general  health  must  be  improved,  as  the  disease 
occurs  in  those  who,  by  their  occupations,  are  much  con- 
fined. I  have  met  with  the  greatest  success  through  the 
use  of  alternate  hot  and  cold  douches  to  the  spine  and 
affected  limb,  followed  by  free  rubbing,  and  massage,  and 
electricity  in  suitable  cases.  Absolute  rest  is  to  be  enforced 
as  regards  voluntary  exercise  of  the  part,  until  the  case  is 
improving,  when  active  motion  must  be  encouraged.  The 
apparatus,  shown  in  figures  182  and  183,  when  clerks  and 
writers  are  compelled  to  go  on  with  their  work,  are  of  service. 
Neglected  and  severe  cases  may  end  in  atrophic  paralysis. 


353 


CHAPTER  XXII. 

CONTRACTION    OF    THE    PALMAR    FASCIA. 

Definition. — This  deformity  consists  in  flexion  of  one 
or  more  fingers,  which  is  due  to  a  change  in  the  palmar 
fascia  and  its  digital  expansions,  and  also  to  some  secondary 
or  primary  affection  of  the  fibrous  structures  of  the  skin. 

Causes. — Injuries  to  the  palm  of  the  hand,  repeated 
pressure,  or  frictions,  the  rheumatic,  syphilitic,  or  gouty 
diathesis,  and  nerve  changes  may  cause  it.  Chronic  in- 
flammatory changes,  some  occupations,  heredity,  etc.,  have 
been  known  to  produce  it.  In  one  case  of  mine,  in  an 
old  man,  there  was  fibroid  induration  and  contraction 
of  the  fore-skin,  of  a  very  similar  character  to  that  in  the 
palm,  and  I  regarded  the  pathological  changes  as  prob- 
ably identical.  Richet  and  Ricord  have  each  recorded 
cases  due  to  syphilis,  some  of  which  yielded  to  iodide 
of  potassium.  Tamplin  relates  a  case  which  he  con- 
sidered due  to  alcoholism,  and  which  disappeared  when 
beer  and  spirits  were  forbidden,  but  reappeared  on  the 
man  resuming  intemperate  habits,  and  finally  disappeared 
when  he  became  a  total  abstainer.  We  know  that 
contraction  of  the  prepuce  is  met  with  during  old  age, 
and  it  is  not  improbable  that  it  may  be  a  sort  of  local 
cirrhosis  here,  as  in  the  palm.  In  some  cases  of  this 
affection  no  known  cause  can  be  adduced.  It  is  more 
common  in  males  than  females.     I  was  the'  first  to  point 

A    A 


354  BODILY    DEFORMITIES. 

out*  that  it  does  occur  in  females,  and  Mr.  Southam, 
junior,  of  Manchester,  shortly  after  mentioned  other  cases 
occurring  in  women.  As  regards  age,  it  is  commonest  in, 
or  past,  middle  life,  though  I  have  seen  it  occur  in  quite 
young  subjects,  and  there  is  now  a  student  at  the  London 
Hospital  who  has  indurations,  nodules,  and  puckering  in 
the  palm,  over  the  seat  of  both  ring  fingers,  which  he  says 
came  on  after  the  use  of  a  hatchet  for  about  an  hour  only 
on  one  day.  He  is  under  the  impression  that  gout  is  in  the 
family,  but  he  has  had  no  evidence  of  it  in  his  own  person. 
Some  observers  say  that  it  may  also  be  congenital,  and  in 
the  chapter  on  Congenital  Finger  Contraction  I  have  men- 
tioned a  case  of  mine. 

Symptoms. — The  patient  usually  makes  no  complaint  of 
pain,  though  in  some  instances  this  is  remarked.  His 
attention  is  first  drawn  to  the  part  by  a  feeling  of  tightness, 
and  inability  to  completely  extend  the  finger.  Subsequently, 
the  finger  begins  to  contract,  and  the  proximal  phalanx  is 
flexed  upon  the  metacarpal,  and  the  second  upon  it,  the 
third  phalanx  remaining  free  as  a  rule,  though  figures  16 
and  19  of  Mr.  Adams's  book, t  represent  it  as  flexed.  At  a 
later  stage  there  exist,  usually,  subcutaneous  longitudinal 
bands  from  the  palm  of  the  hand  along  the  digital  prolong- 
ations of  the  palmar  fascia.  These  sometimes  run  in  a  line 
with  the  fingers,  and  sometimes  between  them,  affecting 
the  prolongations  of  adjoining  fingers.  They  can  be  traced 
to  the  anterior  portions  of  the  first  two  phalanges,  and  are 
usually  more  or  less  concave  towards  the  palm,  though 
there  may  be  nodules  in  their  course.  The  skin  is  often 
thickened  and  adherent,  having  lost  its  mobility ;  it  is  also 
dry  and  shows  radiating  furrows.     This  portion  of  skin  may 

*  British  Medical  Journal,  1881,  p.  1049. 

t  "Observations  on  Contraction  of  the  Fingers,"  &c.,  London. 
1879. 


CONTRACTION    OF    THE    PALMAR    FASCIA. 


355 


at  first  perspire  abnormally,  but  subsequently  it  becomes 
dry  and  roughish.  In  a  later  stage,  the  fingers  are  tightly 
bent  into  the  palm,  and  cannot  be  at  all,  or  very  little,  ex- 
tended, even  passively,  and,  if  this  be  attempted,  these 
bands  will  stand  out  and  be  felt  to  be  quite  hard  and  tense. 
The  ring  and  little  fingers  are  most  commonly  affected  ; 
the  middle  and  index  less  commonly,  and  the  thumb  least 
of  all,  though  other  observers,  as  well  as  myself,  have  seen 


Fig    184. — Contraction  of  right  ring  and  little  fingers. 


individual  cases  of  the  last  condition.  The  affected  fingers 
are  generally  flexed  in  unequal  degrees,  and  the  disease  may 
affect  one  or  both  hands. 

Pathology — It  has  been  clearly  shown  that  the  principal 
change  is  in  the  palmar  fascia  and  its  digital  prolongations, 
and  that  the  tendons,  if  affected,  are  only  secondarily  so, 
and  in  severe  or  late  stages  of  the  affection.  These  pro- 
longations may  be  longitudinal  or  transverse,  the  latter  are 

a  a  2 


356  BODILY    DEFORMITIES. 

never  seen  without  the  former.  There  are  usually  two  sets  ; 
a  superficial  and  deep,  the  former  passing  to  the  skin,  the 
latter  to  the  sides  of  the  first  and  second  phalanges,  to  the 
periosteum,  and  to  the  sheaths  of  the  tendons.  Dupuytren, 
Goyrand,  Sanson,  and  Partridge  have  shown  by  their  dissec- 
tions that  it  is  the  fascia,  not  the  tendons,  which  are 
affected.  The  pathological  question  then  arises — What  is 
the  nature  of  the  change  ?  Some  consider  it  a  hypertrophy 
of  pre-existing  fibres  ;  others  think  that  there  is  a  new  forma- 
tion of  fibrous  tissue  with  contractions,  forming  indurations  ; 
others,  that  these  are  veritable  fibromata ;  others,  that  the 
disease  is  a  cicatricial  hyperplasia  of  the  palmar  fascia  ; 
and  Konig  regards  it  as  a  manifestation  of  the  fibroid  dia- 
thesis. 

Recently,  Baum  of  Dantzic  has  revived  the  opinion  of 
Malgaigne,  that  it  is  due  to  a  degenerative  process  of  the 
skin  extending  to  the  subjacent  fascia ;  but  he  attributes 
this  obversation  to  Pitha.  He  says,  "  If  in  making  a  dissec- 
tion one  isolates  the  aponeurosis,  and  then  if  one  pinches 
up  a  fold  sufficient  to  reduce  the  length  of  the  aponeurosis 
a  half,  only  a  slight  flexion  of  the  fingers  at  the  metacarpo- 
phalangeal joint  is  produced,  and  this  can  be  easily  over- 
come." One  cannot,  if  the  fingers  be  extended,  repeat  this 
experiment  on  the  skin,  because  this  is  so  economised  in 
the  palm  that  it  is  impossible,  but  if  the  hand  be  flexed, 
(this  can  be  done  on  one's  own  hand),  and  if  only  a  small 
portion  of  the  transverse  fold  formed,  be  grasped  with  the 
finger  and  thumb  of  the  opposite  hand,  the  extension  of  the 
corresponding  finger  is  almost,  or  quite,  impossible.  If, 
on  the  cadaver,  this  fold  be  excised,  it  will  be  seen  that  it  is 
formed  entirely  by  the  skin  and  a  little  subcutaneous 
cellular  tissue.  It  is  this  economical  disposition  of  the 
skin  which  produces  the  feeling  of  constriction  which 
one  feels  in  complete  extension  of  the  fingers. 


CONTRACTION    OF   THE    PALMAR    FASCIA.  357 

He  regards  the  fact  that  this  tissue  most  commonly  begins 
in  the  ring  finger,  as  supporting  his  cutaneous  theory.  In 
the  position  of  rest,  the  fingers  are  semi-flexed ;  and  in  com- 
plete flexion,  as  in  making  a  fist,  the  other  fingers  meet  the 
thenar  and  hypo-thenar  eminences,  while  the  ring  finger  is 
in  the  groove  which  separates  them.  Its  extension  is  there- 
fore greater,  and  comparatively  slight  alterations  of  the 
skin  will  affect  it,  while  they  will  not  be  perceived  by  the 
others.  Moreover,  the  deepest  part  of  the  palm  corresponds 
to  the  ring  finger  and  becomes  more  compressed  in  grasp- 


FiG.  185.—  Dupuytren's  contraction.     Goyrand's  dissection.     1.  The  digital  pro- 
cesses of  the  palmar  fascia. 


ing  efforts,  as  in  ordinary  occupations  or  pastimes  requiring 
firm  use  of  the  hand,  and  thus,  the  skin  may  become  slowly 
inflamed,  and  form  fibrous  bands.  He  regards  Goyrand's 
illustration  as  evidence  of  hyperplastic  changes  in  the  skin, 
having  a  similar  origin  to  corns,  which  are  developed  by  a 
chronic  inflammatory  process  due  to  repeated  pressure  and 
friction. 

The  fact  that  the  thumb  may  be  affected  lends  support  to 
the  skin  theory.  In  the  palm  of  the  hand,  that  which 
renders  anatomical  diagnosis  difficult,  is  the  existence  of 
numerous  adhesions  between  the  skin  and  aponeurosis,  and 


358  BODILY   DEFORMITIES 

it  depends  upon  the  dissector  as  to  whether  the  main  part  of 
the  new  tissue  be  found  connected  with  the  skin,  or  the  apon- 
eurosis ;  and,  moreover,  Busch's  operation,  which  makes 
a  skin  flap  and  does  not  touch  the  aponeurosis,  proves  by  its 
success  that  the  change  is  in  the  skin.  Baum  concludes  that 
in  this  malady  the  aponeurosis  plays  a  considerable  part,  and 
that  chronic  inflammation  of  this  is  the  first  stage,  but  that 
soon,  to  relieve  the  pain  due  to  this,  the  ringer  becomes 
semi-flexed,  and  if  to  this  flexion,  which  at  first  is  secondary, 
a  permanent  contraction  occurs,  then  a  cicatricial  tissue  is 
formed  in  the  skin  which  causes  this  flexed  condition.  He 
does  not  furnish  any  pathological  preparation  to  support 
his  view,  but  relies  upon  the  benefit  afforded  by  Busch's 
operation. 

Lanceraux,  in  1881,  had  the  opportunity  of  dissecting 
both  hands  of  a  man  aged  sixty-one,  a  varnisher,  and  the 
experiment  of  removing  the  skin,  which  was  intimately 
adherent  to  the  aponeurosis,  showed  that  the  movements 
were  not  at  all  affected,  i.e.,  that  the  finger  could  not  be 
straightened  after  its  removal.  The  skin  was  considerably 
thickened,  and  the  contraction  was  due  to  a  longitudinal 
band  of  palmar  fascia  which  passed  to  the  base  of  the 
second  phalanx,  the  flexor  tendons  were  perfectly  free ;  the 
microscopic  examination  of  the  skin  by  Variot  is  very 
interesting.  Under  a  low  power,  he  found  the  skin  con- 
siderably thickened,  the  papillae  were  normal,  but  the  deep 
layer  of  the  skin  passed  without  interruption  into  a  thick 
layer  of  fibrous  tissue,  all  of  which  was  stained  rose-colour 
with  carmine.  It  was  in  this  subcutaneous  fibrous  tissue 
that  the  change  was  found.  The  tendons  and  their  sheaths 
were  intact,  and  in  those  portions  of  the  metacarpo-phalan- 
geal  joint  which  were  in  contact,  the  cartilages  were  normal, 
but  they  were  eroded  and  yellowish  at  the  posterior  parts 
of  the  heads  of  the  metacarpals.     The  skin,  under  the 


CONTRACTION    OF    THE    PALMAR    FASCIA.  359 

higher  power,  showed  that  the  superficial  layers  of  the 
epidermis  had  undergone  incomplete  carnification.  The 
cells  were  polyhedric,  the  nuclei  became  coloured  with 
carmine,  and  somewhat  resembled  the  epithelial  covering  of 
the  mucous  membrane.  This  imperfect  transformation  of 
the  epidermis  is  attributed  to  the  immobility  of  the  part 
protecting  it  from  friction.  The  papillae  and  the  true  skin 
were  very  slightly  altered,  the  latter  being  a  little  thickened. 


Fig.   186— Dupuytren's  contraction  and  nodules  on  left  ring  and  little  fingers. 

This  deeper  layer  was  devoid  of  fat,  and  was  continuous 
with  the  subjacent  fibrous  tissue  by  similar  tissue,  somewhat 
less  tense.  At  some  points,  the  walls  of  the  sudoriferous 
glands  appeared  thicker  than  normal,  but  their  epithelium 
was  preserved.  The  fibrous  tissue  causing  the  contraction 
consisted  of  a  very  coherent  fibrillar  tissue,  like  tendon 
tissue.  Its  fibres  were  extremely  close,  and  were  devoid  of 
fibro-plastic  interlocated  cells,  and  of  elastic  tissue.  It 
was,  in  fact,  a  scirrhous  cicatricial  tissue. 


0 


6o  BODILY   DEFORMITIES. 


This  case  clearly  shows,  that  besides  the  much  increased 
thickness  of  the  aponeurosis,  certain  changes  of  the  skin 
and  subcutaneous  cellular  tissue  were  observed.  The 
thickening  of  the  epidermis  and  of  the  skin,  the  disappear- 
ance of  the  fatty  areola?,  and  the  interposition  of  a  tense 
tissue  uniting  the  skin  to  the  aponeurosis,  or  rather  making 
one  layer  of  both,  so  close  that  they  had  to  be  artificially 
divided,  and  the  thickening  of  the  sudoriferous  glands, 
show,  that  whether  primarily  or  secondarily,  the  skin  is  con- 
sideraly  affected.  It  will  thus  be  seen  that  this  cirrhosis 
extends  to  all  the  fibrous  tissue  of  the  affected  parts ;  skin, 
cellular  tissue,  aponeurosis,  and  ligaments,  are  indurated, 
thickened  and  contracted. 

O.  W.  Madelung*  considers  the  contraction  as  secondary, 
and  that  the  first  pathological  change  consists  in  the  dis- 
appearance of  the  fat  pellets  from  between  the  fibres  of 
the  palmar  fascia,  and  also  between  the  prolongations 
which  it  sends  to  the  skin.  He  says  that  age  produces  the 
disappearance  of  this  fat,  but  traumatism  and  inflammation 
also.  The  fatty  tissue  serves  to  protect  the  deeper  layers 
against  pressure,  and  when  it  has  disappeared,  certain  parts 
of  the  palm,  more  exposed  than  others,  may  be  injured  by 
frequent  pressure,  especially  at  the  heads  of  the  metacarpals. 
This  repeated  pressure  produces  inflammation,  then  hyper- 
plasia, and  retraction  of  the  fibrous  cords.  When  the  re- 
traction has  reached  a  certain  stage,  the  patient,  by  attempt- 
ing to  straighten  the  finger,  only  aggravates  the  lesion,  and 
when  the  flexion  of  the  fingers  is  such  that  the  patient  can 
no  longer  use  them,  the  malady  stops,  and  it  is  then  that 
Busch's  operation  succeeds,  for  it  removes  the  protuberance 
formed  by  the  cellular  tissue  of   the  palm  of  the  hand. 

*  "The  Causes  and  Operative  Treatment  of  Dupuytren's  Finger 
Contraction."  Translated  and  published  by  the  late  Mr.  Trubner, 
London,  1876. 


CONTRACTION    OF    THE    PALMAR    FASCIA. 


361 


Madelung  is  therefore  a  believer  in  traumatism  as  a  cause, 
and  his  theory  serves  simply  to  explain  how  traumatism 
produces  retraction. 

Dr.  Robert  Abbe*  has  recently  advocated  a  nervous 
origin  for  this  disease.  He  says  that  there  is  first,  a  slight 
injury ;  second,  a  spinal  impression  produced  by  this  peri- 
pheral irritation;  third,  a  reflex  influence  on  the  part 
originally  hurt,  producing  nutritive  disturbances  and  new 


Figs.  187  and  188—  Palmar  and  lateral  dissection  of  fingers,  to  show  the  processes 
of  the  palmar  fascia.  A,  New  formed  process  ;  C,  Longitudinal  processes ;  P., 
Transverse  processes  strengthening  sheath.  In  the  lateral  view  B  points  to  the 
longitudinal  and  E  to  the  transverse. 

growth,  manifested  by  the  contracting  fascial  bands,  and 
occasional  joint  lesions  resembling  subacute  rheumatism ; 
fourth,  through  the  tense  contractions,  a  secondary  series 
of  reflex  symptoms,  neuralgias,  general  systemic  disturb- 
ances, and  a  reflection  of  the  trouble  to  the  corresponding 
parts  of  the  opposite  hand.  He  combats  the  gouty  origin 
of  the  contraction,  and  thinks  that  the  local  mischief  is— 
reflexly— responsible  for  many  of  the  symptoms  which  have 
*  New  York  Medical  Journal,  April  19  and  26,  1884. 


362  BODILY    DEFORMITIES. 

been  attributed  to  gout.  Mr.  W.  Adams  read  a  paper  on 
this  subject  at  the  Copenhagen  meeting  of  the  Interna- 
tional Medical  Congress,  adhering  to  the  gouty  origin  of 
the  contraction.  Mr.  N.  Smith  also  lately  made  a  communi- 
cation to  the  Medico-Chirurgical  Society  concerning  it. 

Diagnosis. — This  is  generally  very  easy,  as  the  affection 
of  the  two  or  three  last  fingers,  and  especially  of  the  ring 
finger,  the  slow  progress  of  the  disease,  the  presence  of 
the  palmar  bands,  and  often  of  nodules,  the  thickening  and 
adherence  of  the  skin,  the  flexion  of  the  first  two  phalanges 
leaving  the  third  free,  all  serve  to  differentiate  it  from 
cicatricial  contractions,  and  from  inflammatory  or  nervi- 
muscular flexions  of  the  digits.  In  cases  of  lesions  of  the 
nerves  of  the  arm,  whether  from  injury  or  nervous  disease, 
the  flattening  of  the  thenar  or  hypothenar  eminences,  the 
affection  of  the  interossei,  the  falling  of  the  wrist,  the 
Griffin-hand,  and  the  absence  of  palmar  bands,  will  serve 
to  differentiate  it. 

There  may,  however,  be  slight  difficulty  in  diagnosing  it 
from  retraction  of  the  flexor  sublimus,  the  profundus  re- 
maining intact.  In  such  cases  the  first  two  phalanges  will 
be  flexed,  but  there  will  be  no  palmar  bands,  and  on 
endeavouring  to  straighten  the  fingers,  the  movement  will 
be  transmitted  to  the  tendons  of  the  sublimus  above  the 
wrist,  and,  with  care,  there  is  no  fear  of  confounding  this 
result  with  the  traction  put  upon  the  palmaris  longus  when 
the  fingers  are  attempted  to  be  straightened  in  cases  of 
Dupuytren's  contraction. 

Treatment.— This  is  of  course  chiefly  surgical,  though 
in  gouty,  rheumatic,  or  syphilitic  cases,  appropriate  medical 
means  must  be  adopted.  The  surgical  treatment  consists 
in  either  gradual  extension,  or  in  operation.  The  former  is 
carried  out  by  means  of  light  though  effective  machines 
applied  on  the  dorsum  of  the  hand,  and  the  force  should 


CONTRACTION    OF    THE    PALMAR    FASCIA.  363 

be  a  constant  one.  It  is  only  applicable  to  the  slighter 
cases,  the  severer  ones,  or  those  of  long  standing,  are  only 
amenable  to  operation. 

Two  chief  methods  have  been  devised  for  dividing  the 
tense  bands  of  the  palmar  aponeurosis,  that  by  open  wound, 
and  the  subcutaneous  method.  The  former  comprises  several 
methods,  viz.,  those  of  Dupuytren,  Goyrand,  Caesar 
Hawkins,  Richet,  Sir  William  Fergusson,  Busch  and  Post. 

Open  division.—  Dupuytrerts    operation    is    thus    per- 
formed :  the  hand  being  firmly  fixed  and  the  finger  brought 
towards  extension,  a  transvere  incision  is  made  across  the 
metacarpo-phalangeal   articulation    of    the   ring,    which  is 
commonly  the  affected  finger.     This  incision  first  divides 
the  skin,  then  the  palmar  aponeurosis,  which  yields  with  a 
crackling  noise,  and  the  finger  can  then  be  straightened  ; 
another  transverse  incision   was    obliged  to    be  made  in 
Dupuytren's  case  opposite  the  joint  of  the  first  and  second 
phalanges  of  the  little  finger.     He  then  separated  the  skin 
from  the   aponeurosis    by    another   incision    opposite   the 
metacarpo-phalangeal    joint.     The    second   and   third   in- 
cisions had  only  a  partial  effect,  but  another  one  opposite 
the  middle  of  the  first  phalanx  of  the  little  finger  resulted 
in  its  being  easily  extended,  and  this  result  showed  that 
the  incision  had  divided  the   point   of   insertion   of   the 
aponeurotic  digitation.     The  fingers  were  put  up  extended. 
The  operation  was  followed  by  a  good  deal  of  swelling  and 
suppuration,    and   the    healing   proceeded   in    an   inverse 
manner,  i.e.,  that  the  incision  first  made,  healed  last.     The 
patient  subsequently  recovered  with  useful  fingers.    Dupuy- 
tren records  the  other  successful  cases  in  the  same  volume.* 
Goyrand's  operation  :    Goyrand,   of  Aix,   made  longitu- 
dinal incisions  over  the  facial  bands  or  abnormal  fibrous 
fasciculi,  as  he  termed  them,  and  divided  the  latter  trans- 
*  "  Legons  Orales,"  T.  1,  p.  3. 


364  BODILY    DEFORMITIES. 

versely.  The  skin  he  separated  from  the  fibrous  bands 
before  the  latter  were  incised.  The  fingers  were  put  up  in 
complete  extension,  and  he  says  that  the  incisions  united 
by  first  intention.  He  remarks,  that  if  the  pre-digital 
bridles  send  out  prolongations  to  the  first  phalanges,  before 
inserting  themselves  into  the  second,  one  should  cut  them 
above  and  below  the  prolongations.*  The  longitudinal 
skin  incision,  prevents  the  gaping  which  occurs  on  straight- 
ening the  finger,  if  the  skin  be  transversely  incised. 

CcBsar  Hawkins's  method:  Mr.  Hawkins  operated  on 
two  men,  one  aged  thirty  the  other  thirty-nine.t  He  made 
one  transverse  incision  in  the  palm  for  division  of  the  large 
facial  bands,  and  semi-circular  incisions  at  the  base  of  the 
little  and  ring  fingers  for  the  division  of  the  digital 
prolongations  of  the  fascia.  Mr.  Hawkins  said  of  one 
patient  aged  thirty,  "  he  has  as  much  power  over  the  fingers 
which  were  operated  upon  as  any  other."  This  surgeon 
had  in  his  mind  prior  to  this  operation  the  question  of 
subcutaneous  division  of  these  bands,  which,  however, 
was  first  suggested  by  Sir  Astley  Cooper  in  1822. 

Richefs  plan  : — In  certain  cases  where  the  bands  are 
thick  and  nodulated,  Goyrand's  proceeding  is  insufficient,  so 
Richet  made  a  longitudinal  incision  over  them,  and  a  short 
transverse  one  at  each  end,  and  dissected  all  the  flaps  thus 
formed,  as  far  as  necessary.  He  then  cut  or  excised  the 
band,  the  flaps  were  united  and  the  finger  fixed  in  extension. 
In  one  case  he  had  an  excellent  result. 

Sir  William  Fergusson's  plan : — This  is  very  similar  to 
Richet's.  Mr.  John  Gay  operated  in  a  case  by  this  method, 
and  Mr.  W.  Adams  states  that  suppurative  inflammation 

*  Memoires  de  VAcademie  Royale  de  Medecine,  T.  3,  and  Gazette 
Medicate  de  Paris,  1834-5. 

t  Medical  Gazette,  1835  and  1 844.  Also  contributions  to  Pathology 
and  Surgery,  1874. 


CONTRACTION    OF    THE    PALMAR    FASCIA.  365 

followed,  and  the  articulation  was  involved,  but  ultimately, 
however,  the  case  did  well,  though  the  joint  remained 
permanently  stiff. 

Busclis  operation: — Madelung*  has  drawn  attention  to 
the  treatment  of  this  affection  by  Professor  Busch,  of  Bonn. 
It  consists  in  dissecting  up  a  triangular  flap  of  skin  from  the 
contracted  palmar  band,  and  then  dividing  all  the  bands  of 
the  fascia  which  are  exposed,  or  can  be  reached.  The  base 
of  the  flap  is  in  the  groove  which  separates  the  flexed  finger 
from  the  palm  of  the  hand,  and  the  apex  is  at  the  highest  part 
of  the  band,  which  becomes  prominent  when  the  finger  is  put 
towards  extension.  The  flap  is  dissected  from  apex  to  base, 
and  it  should  comprise  as  much  subcutaneous  cellular  tissue 
as  possible.  As  one  proceeds  with  this  dissection,  numerous 
fibres  of  communication  between  the  skin  and  aponeurosis 
are  cut,  and  the  fingers  can  be  a  little  extended.  The  flap 
being  reflected,  constant  attempts  at  extension  of  the  finger 
must  be  made,  and  all  resisting  fibrous  bands  must  be 
divided  from  without  inwards,  with  slight  cuts  of  the  knife. 
If  one  proceed  thus,  there  is  little  fear  of  injuring  a  tendi- 
nous sheath ;  the  finger  slowly  comes  into  extension,  the 
skin  flap  strongly  retracts,  and  its  apex  turns  rather  inwards. 
When  the  finger  is  extended  a  portion  of  the  wound  is 
uncovered.  Sometimes  the  angles  of  the  wound  may  be 
united,  but  if  there  is  risk  of  suture-tension,  this  had  better 
not  be  attempted.  If  several  fingers  be  affected,  two  may 
be  operated  on  at  one  time.  .  A  bandage  closes  the  wound, 
the  hand  is  kept  in  a  sling,  and  no  attempt  at  extension  is 
made  until  the  wound  has  entirely  closed,  and  then  only 
slight  extension  is  employed  by  passing  wood  cylinders  of 
various  sizes  into  the  palm.  Skin-grafting,  to  accelerate  the 
healing  of  the  wound  may  be  used,   but  cicatrization  is 

*  Berliner  Klinische  Wochenschrift,  Nos.  15  and  16,  1875  ;  and  an 
English  Translation  by  Mr.  Trubner,  1876. 


$66  BODILY    DEFORMITIES. 

usually  accomplished  in  three  or  four  weeks.  Several 
successful  cases  are  recorded,  but  one  case,  even  under  the 
use  of  Listerism,  suppurated,  and  the  flexor  tendon  of  the 
little  finger  sloughed.  Madelung  says  that  this  operation 
presents  no  important  disadvantages.  It  is  not  painful, 
there  is  no  fear  of  suppurative  inflammation,  haemorrhage, 
synovitis,  nor  tetanus.  Tendinous  sheaths  are  easily  noticed 
and  .avoided,  vessels  are  readily  seen  and  tied,  and  healing 
proceeds  as  in  a  simple  tegumentary  wound. 

Posts  operation  :  Dr.  A.  C.  Post,  of  New  York,*  in  con- 
traction of  the  palmar  fascia  and  of  the  sheaths  of  the  flexor 
tendons,  makes  small  incisions  at  various  points,  as  he 
thinks  that  the  adhesion  between  the  aponeurosis  and  the 
skin,  prevents  the  strictly  subcutaneous  section  being  made. 
The  fingers  are  immediately  extended  and  fixed  to  a  splint, 
the  dressings  removed  every  two  or  three  days,  and  passive 
motion  used.  Only  one  of  the  five  cases  related  in  this 
paper  was  true  Dupuytren's  contraction,  the  others  depend- 
ing on  inflammations  of  the  tendinous  sheaths. 

Mr.  W.  Adamsf  says  that  when  in  America  in  1876  he 
conversed  with  Professor  Post,  who  thought  that  the  firm 
adhesion  between  the  skin  and  fascia  prevented  the  knife 
from  being  passed  between  them.  He  says,  "  I  explained, 
however,  that  the  close  adhesion  between  the  skin  and  the 
cord — even  in  very  severe  cases — never  extends  through 
the  entire  length  of  the  cord,  and  that  by  flexing  the  hand 
at  the  time  of  operation  it  was  possible  to  introduce 
the  small  fascia  knife  under  the  skin,  and  pass  it  between 
the  skin  and  the  cord,  generally  at  the  two  extremities  of 
the  latter,  where  the  skin  was  not  adherent  to  the  cord. 
This  allows  of  an  immediate  gain  by  extension ;  and  that 

*   "Archives  of  Clinical  Surgery,"  1876. 

+  "Observations  on  Contractions  of  the  Fingers,"  London,  1879, 
P-  37. 


CONTRACTION    OF   THE    PALMAR    FASCIA.  367 

portion  of  the  cord  at  which  close  adhesions  of  the  skin 
exists  being  thus  isolated  and  freed  from  tension,  undergoes 
a  gradual  process  of  atrophy  and  absorption,  just  as  all  the 
knotty  cutaneous  thickenings  do  after  the  subcutaneous 
division  of  the  fascial  bands." 

Subcutaneous  operations— Sir  Astley  Cooper  in 
1822*  first  suggested  this  operation,  and  Bransby  Cooper, 
his  nephew,  applied  the  subcutaneous  method  with  success 
in  a  case  of  retraction  of  the  plantar  aponeurosis.  Astley 
Cooper's  suggestion  was  made  long  before  Dupuytren's 
writings  on  palmar  contraction,  and  before  the  reintroduc- 
tion  of  subcutaneous  tenotomy  by  Stromeyer.  Sir  A. 
Cooper's  operation  was  not  performed  strictly  according  to 
our  present  notions  of  subcutaneous  methods  ;  still  it  was  a 
very  near  approach  to  it,  and  there  can  be  no  doubt  that 
the  merit  of  his  plan,  as  well  as  that  of  putting  the  finger 
up  in  extension  after  the  operation,  is  due  to  him.  He  also 
recognized  the  fact  that  the  malady  was  due  to  contracted 
fascia,  and  not  to  contraction  or  retraction  of  tendons,  or 
inflammation  of  their  sheaths,  though  Little,  as  recently  as 
1870T  states  that  the  flexor  tendons  are  implicated  in  the 
contraction ;  and  BryantJ  considers  that  the  flexor  tendons 
as  well  as  the  palmar  fascia  produce  the  contraction. 
Lonsdale  and  Tamplin  also  held  the  same  view. 

Jules  Gu'eriris  operation  : — Gue'rin  appears  to  have  been 
the  first  who  divided  contracted  fingers  by  the  subcutaneous 
plan,  and  though  he  spoke  of  the  necessity  of  dividing 
flexor  tendons,  and  stated  that  he  not  only  obtained  perfect 
union  of  their  divided  extremities  without  adhesions,  but 
that  the  movement  of  the  fingers  was  well  preserved,  he 

*  "  Treatise  on  Dislocations  and  Fractures  of  the  Joints."  In  the 
chapter  on  "Dislocations  of  the  Fingers  and  Toes." 

t  "Holmes's  System  of  Surgery,"  Second  Edition,  Vol.  3,  p.  698. 

t  "Practice  of  Surgery,"  Third  Edition,  Vol.  2,  p.  323,  London, 
1879. 


368  BODILY   DEFORMITIES. 

undoubtedly  adopted  the  subcutaneous  method  for  the 
treatment  of  this  deformity. 

Sir  William  Fergussoris  plan  consisted  in  passing  a 
narrow  knife  between  the  skin  and  contraction,  and  carrying 
it  through  the  most  prominent  band,  whether  this  be  merely 
aponeurosis,  tense  cellular  tissue,  or  tendons.  The  fingers 
were  subsequently  gradually  extended. 

W.  Adams's  operation  : — This  consists  in  making  multiple 
subcutaneous  divisions  of  the  fascia  and  its  digital  prolonga- 
tions, and  I  will  use  Mr.  Adams's  words  as  far  as  possible  : 
The  small  tenotome,  or  fascia-knife,  is  passed  between  the 
skin  and  the  tense  band,  which  is  then  slowly  and  cautiously 
divided,  taking  care  not  to  dip  the  point  of  the  instrument 
or  to  divide  any  structures  except  the  contracted  band. 
The  operation  is  better  confined  to  one  or  two  fingers,  if 
many  be  contracted,  and  from  four  to  six  punctures  may  be 
made  in  different  places  if  necessary.  The  first  puncture 
is  made  in  the  palm  of  the  hand,  between  the  transverse 
crease  and  the  annular  ligament,  at  a  point  where  the  skin 
is  not  tightly  stretched  over  the  hand,  and  where  it  is  not 
adherent  to  the  fascia.  The  second  puncture  should  divide 
the  same  cord  as  the  first,  but  as  near  to  the  finger  as 
possible,  between  the  transverse  crease  and  the  web  of  the 
finger,  thus  leaving  the  contracted  band  in  the  palm  of  the 
hand,  where  adherent  to  the  skin,  isolated,  and  cut  off  from 
its  connexions,  on  its  upper  and  lower  extremities.  The 
third  and  fourth  punctures  divide  the  lateral  digital  pro- 
longations. These  must  be  divided  very  carefully,  in  order 
to  avoid  cutting  the  vessels  and  nerves  along  the  sides  of  the 
fingers.  The  puncture  should  be  made  at  the  bifurcation  of 
the  cutaneous  web  between  the  fingers,  and  the  incisions 
directed  obliquely  upwards  and  outwards,  towards  the  palm 
of  the.  hand.  These  incisions  will  divide  the  strongest  and 
most  prominent  bands  which  produce  the  flexion   of  the 


CONTRACTION    OF    THE    PALMAR    FASCIA. 


I69 


first  phalanx  of  the  finger  upon  the  hand,  and  if  care  be 
taken  to  avoid  dipping  the  point  of  the  knife,  there  will  be 
no  fear  of  wounding  vessels  or  nerves. 

Sometimes  lateral  bands  and  contracted  fascia  require  to 
be  divided  opposite  the  centre  of  the  first  phalanx,  and  this 
must  be  done  by  puncture  at  the  edge  of  the  contracted 
bands,  the  knife  being  directed  transversely  towards  the 
band ;  but  this  cut  must  be  made  very  carefully,  to  avoid 
the  artery  and  nerve,  the  surgeon  re- 
membering that  the  band,  though  tough 
and  strong,  is  at  the  same  time  very 
thin.  Occasionally,  a  lateral  band  may 
have  to  be  divided  between  the  first 
and  second  phalanx,  or  one  on  either 
side,  at  a  point  corresponding  to  the 
articulation,  and  this  must  be  done 
carefully  and  with  the  precautions  just 
described.  Central  incisions  in  front 
of  either  the  first  or  second  phalanx 
should  be  avoided,  as  the  sheaths  of 
the  tendons,  or  the  tendons  them- 
selves, may  be  readily  divided  by  such 
incisions,  and  would,  if  the  finger  were 
put  up  in  complete  extension,  lead  to 
loss  of  flexing  power. 

A  pledget  of  lint  is  immediately  ap- 
plied over  each  puncture,  and  retained  by  plaister.  Sub- 
cutaneous haemorrhage  is  thus  arrested,  and  the  hypo- 
dermatic character  of  the  operation  is  preserved.  An 
additional  compress  of  lint  should  be  applied,  and  the 
fingers  bandaged  to  the  splint  in  an  extended  position. 

After  division,  the  fingers  are  straightened  at  once,  the 
object  being  to  widen  the  gaps  in  the  fascia  as  much  as 
possible,  with  the  view  of  preventing  union,  and  of 
lengthening    the    contracted    band  by  intermediate   new 

B    B 


Fig.  189. — Instrument 
with  cog-wheel  arrange- 
ment to  be  worn  after 
division  of  the  palmar 
fascia. 


370  BODILY    DEFORMITIES. 

material.  This  proceeding  is  just  the  reverse  to  that  we 
desire  to  obtain  after  subcutaneous  tenotomy.  The  splint 
is  not  removed  until  the  fourth  day,  unless  there  be  pain  or 
swelling,  when  the  punctures  will  be  found  healed.  It  is 
then  reapplied,  and  extension  kept  up  day  and  night  for  two 
or  three  weeks,  the  splint  being  changed  every  two  or  three 
days.  After  this  the  splint  is  only  worn  at  night  for  three 
or  four  more  weeks,  and  passive  and  active  movements  are 
made  use  of  during  the  day.  I  was  the  first  to  adopt 
immediate  extension  after  division,  and  Mr.  Adams  subse- 
quently followed  the  practice. 

In  cases  of  old  standing,  and  in  those  in  which  the 
second  phalanx  is  sharply  flexed  upon  the  first,  immediate 
extension  after  tenotomy  cannot  always  be  carried  out. 
This  arises  from  two  causes  :  first — the  difficulty  of  dividing 
all  the  contracted  fascial  bands  in  the  neighbourhood  of 
the  joint,  without  risk  to  vessels,  nerves,  tendons,  or  even 
the  joint ;  secondly — the  risk  of  tearing  the  skin,  if  immediate 
and  complete  extension  should  be  attempted  by  any  forcible 
manipulation.  When  the  extension  cannot  be  immediately 
made  to  the  full  extent,  it  must  be  carried  as  far  as  possible 
without  producing  pain,  or  running  the  risk  of  tearing  the  skin. 
In  such  cases,  resort  must  be  made  to  gradual  mechanical 
extension,  which  may  be  commenced  on  the  fourth  day  by 
means  of  an  appropriate  apparatus,  and  even  then,  should 
the  skin  appear  thin  and  shiny,  extension  will  have  to  be 
intermitted. 

Relapse  of  the  contraction  is  rare,  Mr.  Adams  says, 
after  this  method  of  treatment,  and  he  thinks  that  it  is 
prevented  by  multiple  division  and  by  immediate  straighten- 
ing. He  has  never  known  more  than  partial  relapse  in  a 
few  difficult  cases  out  of  a  large  number,  and  in  these,  any 
bands  that  have  escaped  division,  or  any  which  may  have 
since  become  prominent  by  the  extension,  should  be 
subcutaneously  divided,  and  the  disposition  to  recontraction 


CONTRACTION    OF    THE    PALMAR    FASCIA.  37 1 

prevented  at  an  early  stage.  This,  he  says,  contrasts  very 
favourably  with  the  relapsed  cases  after  open  wound,  which 
from  the  nature  of  the  cicatricial  contraction  are  incapable 
of  further  relief. 

I  have  operated  five  times  according  to  Mr.  Adams's 
plan,  once  by  also  dividing  the  tendons,  and  only  once 
by  open  wound,  and  I  certainly  think  that  the  subcutaneous 
method  is  undoubtedly,  in  most  cases,  preferable  to  the 
other;  but  there  are  cases  in  which  the  entire  deformity  is 
only  slowly,  or  after  considerable  difficulty,  cured  by  it.  This 
difficulty  has  been  met  by  other  surgeons.  Goyrand  says, 
that  the  subcutaneous  method  gives  excellent  results  where 
applicable,  but  it  is  only  so  in  rare  and  simple  cases  in 
which  the  retraction  is  caused  by  a  single  band  not 
adherent  to  the  skin,  which  goes  from  the  point  of  origin 
to  the  point  of  insertion  without  sending  out  secondary 
bands,  but,  in  the  more  frequent  cases  of  multiple,  intimate, 
and  disseminated  adhesions,  the  plan  is  insufficient.  Broca 
and  Tillaux  have  had  unsuccessful  cases.  Broca's  case  was 
a  man  aged  forty,  with  gout  or  rheumatism.  He  had  had 
contraction  of  his  ring  fingers  for  nine  years,  subcutaneous 
division,  followed  by  extension  and  tearing  of  the  bands, 
did  not  admit  of  complete  extension,  and  inflammation 
followed.  A  year  afterwards,  the  contraction  returned, 
and  Broca  did  multiple  subcutaneous  section,  avoiding  the 
tendons,  and  then  obtained  nearly  complete  extension  with 
tearing  of  the  skin.  Cicatrisation  took  place  in  fifteen 
days,  and  when  the  patient  was  seen  two  months  afterwards 
there  was  a  tendency  to  reproduction  of  the  retraction.* 
Tillaux's  case  was  very  similar.  Labbe'f  has  recently  had  a 
successful  case  in  a  man  aged  forty,  whose  ring  and  little 
fingers  of  both  hands  became  simultaneously  affected  two 
years  previously.    The  left  hand  was  operated  on  by  Richet, 

*  Roque,  These  de  Paris,  1871. 

+  Jean   Pierre,  These  de  Paris,  1882,  and  Cheviot,  These  de  Paris, 
18S2.  B    B    2 


372  BODILY    DEFORMITIES. 

according  to  Gue'rin's  method  and  the  operation  was  con- 
sidered a  success,  though  rheumatic  mischief  in  the  joint 
prevented  complete  extension.  Labbe  operated  on  the 
right  hand,  in  which  the  fingers  were  in  a  state  of  semi- 
flexion, but  he  did  not  expect  to  entirely  succeed,  and  only 
adopted  it,  intending  to  operate  according  to  Guerin's  mode 
latter  on.  The  operation  resulted  in  a  success,  and  he 
explained  it  by  the  fact  that  the  fingers  were  only  in  semi- 
flexion, that  they  could  be  straightened  by  strong  pressure, 
and  that  the  superficial  situation  of  the  band  facilitated  the 
result. 

My  opinion  is  that  one  should  first  try  the  subcutaneous 
plan,  and  if,  in  severe  cases,  this  should  fail  after  a  fair  trial, 
then  one  of  the  methods  by  open  wound  may  be  adopted, 
and  if  care  be  taken  not  to  interfere  with  the  tendinous 
sheaths,  and  to  avoid  injury  to  vessels  and  nerves,  excellent 
results  may  thus  be  obtained. 

Mr.  McHardie  of  the  Manchester  Infirmary  has,  in  the 
first  number  of  the  Medical  Chronicle,  advocated  a  modifi- 
cation of  Goyrand's  operation  and  adduces  five  encourag- 
ing cases. 

During  the  last  nine  months  four  cases  of  this  malady 
occurred  in  my  practice  at  the  London  Hospital,  and  were 
shown  to  the  class.  Three  of  the  subjects  were  young  men 
aged,  respectively,  nineteen,  twenty-three,  and  twenty-nine, 
showing  that  the  disease  not  unfrequently  occurs  early  in 
life.  The  last  case  occurred  in  a  woman  aged  fifty-two,  a 
washerwoman,  who  had  never  had  gout  or  rheumatism. 
She  attributed  it  to  the  wringing  of  clothes,  but  this  could 
not  have  caused  it.  A  band  existed  corresponding  to  the 
right  ring  finger,  but  on  the  left  there  was  only  a  corneous 
thickening  of  the  skin  over  the  metacarpo  phalangeal 
articulation,  and  this  was  perfectly  movable  on  the  sublying 
tissues.  It  looks  as  if  the  disease  began  in  the  skin  in  her 
case. 


373 


CHAPTER   XXIII. 

JERK,    SNAP,    OR    SPRING    FINGER. 

Definition— This  malady  consists  in  an  obstruction  to 
flexion  and  extension  of  one  or  more  fingers  at  a  certain 
sta°;e  of  these  movements. 

Synonyms.— French,  Doigts  a  Ressort ;  German,  Schnell- 
enden  oder  Federnden  Finger. 

Causes.— This  affection  is  sometimes  due  to  injuries, 
such  as  contusions,  sprains,  &c,  or  it  may  come  on  after 
strong  use  of  the  fingers,  as  in  wringing ;  and  may  also 
result  from  inflammations  of  the  tendinous  sheaths.  In 
some  cases  it  is,  however,  idiopathic.  Rheumatism  or  gout 
may  tend  to  produce  it.  I  think  that  in  some  traumatic 
cases  it  may  possibly  be  due  to  rupture  of  the  tendinous 
sheath  and  hernia  of  the  synovial  fringe. 

Symptoms.— These  consist  in  the  inability  to  com- 
pletely flex  one  or  more  fingers,  more  commonly  the  thumb, 
without,  at  a  certain  stage,  a  resistance,  often  painful,  being 
felt,  and  flexion  can  only  be  completed  by  a  sort  of  little 
jump  or  jerk.  There  is  often  a  circumscribed  swelling  to 
be  felt  along  the  course  of  the  affected  tendon,  and  if  the 
finger  be  placed  along  the  course  of  the  tendon  it  will  be 
found  that  the  obstruction  almost  always  occurs  near  the 
metacarpophalangeal  articulation.  Flexion  having  been 
completed  either  voluntarily,  or  with  the  aid  of  the  other 
hand  forcing   the  finger  into  complete  flexion,  extension 


374  BODILY    DEFORMITIES. 

will  be  found  to  be  obstructed  at  the  same  spot,  and  will  be 
also  accompanied  by  a  jerk,  and,  in  some  cases,  by  an 
audible  snap. 

Pathology,— Notta*  appears  to  have  been  the  first  to 
have  described  this  affection.  In  two  of  his  cases  the  ring- 
finger,  in  one  the  ring  and  middle  finger,  and  in  another 
the  thumb  was  affected.  W.  Buschf  describes  two  cases,  in 
one  of  which,  the  joint  between  the  two  thumb  phalanges, 
and  in  the  other,  the  joint  between  the  first  and  second 
phalanges  of  the  ring-finger  were  affected.  Hahn J  relates  a 
case  occurring  in  a  man  aged  fifty-five,  in  whom  both  ring- 
fingers,  after  an  unusual  long  bout  of  digging,  were  affected 
with  this  malady.  Menzel§  records  a  case  of  a  woman 
aged  forty-two,  who  felt  rheumatic  pains,  and  in  whom  the 
thumb  became  affected.  Berger||  relates  five  cases,  all 
occurring  in  women  of  different  ages.  One  aged  thirty-four, 
after  repeated  rheumatic  pains,  had  the  right  thumb  affected. 
Another  aged  fifty,  after  similar  symptoms,  had  the  same 
digit  affected  after  a  long  bout  of  ironing.  In  the  third 
case,  which  occurred  in  a  young  woman  of  twenty-one, 
after  severe  rheumatic  joint  affection,  the  thumb  became 
affected.  The  fourth  case  occurred  in  a  woman  of  sixty. 
All  these  appear  to  have  been  due  to  rheumatism,  and  the 
condition  of  the  finger  followed  cold  after  washing  clothes. 
The  fifth  case  occurred  in  a  girl  of  five  and  a  half.  Several 
fingers  were  affected  :  in  the  right  hand,  the  thumb,  middle, 

*  Archives  Generates  de  Medecine,  1850,  Series  IV.  T.  24,  p.  142, 
&c 

T  Lehrbuch  der  Chirurgie,  B.  2,  p.  143. 

X  "Ein  Fall  von  federnden  Finger,"  Allg.  Med.  Ceniralztg.,  1874, 
No.  12. 

§  "Ueber  Schnellenden  (Federnde)  Finger,"  Centralblatt fiir  Chi- 
ruj'gie,  1874,  No.  22. 

II  "  Ueber  Schnellenden  Finger,"  Deutsche  Zeitschr.  fiir  Pract.  Med., 
1875,  Nos.  7  and  8. 


JERK,    SNAP,    OR    SPRING    FINGER.  375 

and  ring-fingers  ;  in  the  left,  the  ring  and  little  finger. 
Fieber*  describes  three  cases  ;  one  occurring  in  a  man  aged 
seventy-one,  in  whom  the  middle  finger  of  the  left  hand  was 
affected  after  repeated  pressure  on  it.  The  second  case 
occurred  in  a  woman  aged  fifty-two,  and  followed  a  fall  on 
the  outer  side  of  the  left  hand.  The  third  occurred  in  the 
left  ring-finger  of  a  woman  aged  fifty-eight,  appaiently  after 
playing  for  a  long  time  on  the  clavier.  Vogtf  describes 
three  cases  :  one  affecting  the  right  ring-finger,  the  second 
the  right  thumb,  the  third  the  right  middle  finger,  all  three 
at  the  level  of  the  metacarpo-phalangeal  joint.  FelickiJ 
describes  four  cases  which  occurred  in  the  practice  of 
Prof.  Vogt.  The  first  was  in  a  man  aged  fifty-two,  in 
wmom  the  right  thumb  was  affected  after  an  accident 
causing  hyper-extension.  The  second  in  a  woman  aged 
fifty-six,  occurring  in  the  right  thumb  without  obvious 
cause.  The  third  in  a  man  whose  left  thumb  became 
affected  after  contusion  of  the  same  fore-arm.  The  fourth, 
a  girl  aged  nine,  who,  after  practising  writing,  had  the  right 
middie-finger  affected.  To  these  I  can  add  three  cases 
accurately  observed  during  the  last  three  years,  in  one  of 
which  the  right  thumb,  and  in  the  other  the  right  ring- 
finger,  were  affected.  One  followed  a  whitlow,  and  occurred 
in  an  instrument-maker,  who  often  had  to  exercise  severe 
pressure  on  the  ball  of  his  thumb.  The  case  in  which  the 
ring-finger  was  affected  was  in  a  woman  aged  forty,  and  I 
could  not  get  any  distinct  evidence  of  gout  or  rheumatism. 
The  last  case  that  came  under  my  notice  was  in  the  person 
of  Dr.  Gabriel,  retired  surgeon  of  the  Royal  Navy,  who  has 
kindly  permitted  me  to  use  his  name.     He  first  noticed  his 

*  "  Ueber  den   sogen.  Schnellenden  Finger,"  Wien  Med,  Blatter, 
Nos.  14-17,  1S80. 
t  "  Die  Chirurg.  Krankheiten  der  Obern  Extremitaten,"  1881. 
t  "  Ueber  den  Schnellenden  Finger,"  1881. 


376  BODILY   DEFORMITIES. 

ring-finger  stiff  after  holding  a  heavy  fishing-rod  for  several 
hours.  The  nodule,  the  obstruction  to  motion,  and  the 
snap  when  this  is  overcome,  are  all  well  demonstrated  in 
his  case.     He  is  about  fifty  years  old. 

Bernhardt*  has  recently  recorded  two  cases,  one  occurred 
in  a  woman  aged  sixty-eight,  and  the  other  in  a  man  aged 
forty-nine.  In  both  cases  the  right  middle  finger  was 
affected,  and  in  both  a  contraction  of  the  palmar  fascia 
occurred  before  the  symptoms  of  jerk  finger  began. 

The  pathology  of  these  cases,  in  the  absence  of  any 
dissection,  must,  in  the  meantime,  remain  conjectural;  but 
several  probable  explanations  offer  themselves.  It  appears 
probable  that  the  sudden  and  sometimes  painful  hindrance 
to  motion,  at  a  particular  phase  of  flexion  and  extension, 
sometimes  accompanied  with  audible  snap,  may  be  due  to 
one,  or  more,  of  several  changes.  We  may,  I  think,  dismiss 
the  occurrence  of  a  loose  or  pendulous  body  in  the 
phalangeal,  or  metacarpophalangeal  joint,  as  the  regularity 
of  the  occurrence  at  a  particular  spot  seems  to  do  away 
with  such  an  accidental  cause ;  for  in  such  cases,  though 
hindrance  might,  and  probably  would  occur,  during  the 
motions  of  the  joint,  it  is  improbable  that  it  would  always 
recur  at  a  particular  stage  of  flexion  and  extension.  It  is 
true  that  a  fixed  prominence,  i.e.  deformity  in  a  joint, 
might  produce  these  symptoms  •  but  in  the  cases  observed, 
there  were  other  phenomena,  which  necessitate  quite  other 
explanations.  The  views  of  the  different  writers  on  this 
subject  vary  considerably.  Nelaton,  who  followed  Notta, 
thought  that  the  hard  movable  body,  the  size  of  a  pea, 
which  was  to  be  felt  in  the  metacarpo-phalangeal  joint,  was 
the  cause  of  this  remarkable  affection,  and  von  Pitha  agrees 
with  him.      Menzel  experimentally  proved    Hyrtl's   state- 

*  "Beitrag  zur  Lehre  von  Schnellenden  Finger,"  Centbl.  fiir  Nen- 
krank,  No.  5,  1884. 


JERK,    SNAP,    OR    SPRING    FINGER.  377 

ment  that  a  circumscribed  thickening  of  the  tendon  of  one 
or  other  of  the  long  flexors,  with  simultaneous  narrowing  of 
the  tendinous  sheath,  would  cause  this  peculiar  phenomenon. 
The  hindrance  to  motion  occurs  just  at  the  spot  where  the 
thick  tendon  enters  the  narrow  sheath ;  but  when  it  has 
passed  through  this  channel  further  motion  is  free,  and  just 
as  it  has  passed  through,  the  snapping  sound  is  heard  and 
felt.  Berger  agrees  with  this  vieAv.  Roser  explains  this 
snapping  on  the  supposition  that  there  is  roughness  of  the 
flexor  tendons  at  the  spot  where  the  flexor  sublimis  pierces 
the  profundus.  Lisfranc  supposes  that  the  phenomenon  is 
due  to  a  disease  of  the  tendons  through  the  formation  of 
tendinous  nodules. 

It  would  appear,  I  think,  most  probable  that  the  affection 
is  due  to  a  thickening  of  the  tendinous  sheaths,  which  pro- 
duces hindrance  to  the  free  passage  of  the  tendons  at  a 
particular  spot ;  but  as  the  affection  appears  commonest  in 
the  thumb  {i.e.  in  twenty-eight  cases  it  occurred  eleven 
times  in  the  thumb,  nine  in  the  ring-finger,  six  in  the 
middle,  one  in  the  index,  and  one  in  the  little  finger),  and 
as  the  anatomical  conditions  are  here  different,  we  must 
seek  another  explanation.  In  these  cases  the  commence- 
ment of  the  affection  seems  due  to  a  para-articular  inflam- 
mation of  the  tendinous  sheaths,  and  especially  at  the 
region  of  the  metacarpo-phalangeal  joint.  The  groove  in 
which  the  flexor  longus  pollicis  runs  is  at  this  spot  limited 
by  the  sesamoid  bones,  and  bridged  over  by  a  firm  fibrous 
structure  converting  it  into  a  canal,  and  it  seems,  anatomi- 
cally, highly  probable  that  the  slightest  thickening  of  the 
tendon,  or  its  synovial  sheath,  would,  at  this  spot,  lead  to 
obstruction  in  its  motions. 

In  the  other  fingers  there  are  similar  firm  osteo-fibrous 
canals  for  the  flexors  on  the  proximal  and  middle  phalanges, 
which  are  strengthened  by  the  transverse  and  crucial  bands. 


378  BODILY    DEFORMITIES. 

Here,  it  is  probable,  that  the  hindrance  to  motion  may  occur 
either  through  thickening  of  the  tendon  or  tendons,  the 
canal  being  normal ;  or  through  narrowing  of  the  canal,  the 
tendon  being  normal ;  but  at  these  spots,  in  the  cases 
related,  the  obstruction  was  not  to  be  felt.  It  was  found 
higher  up  in  the  shape  of  a  circumscribed  lump  near  the 
metacarpo-phalangeal  joint,  and,  therefore,  the  obstruction 
was  at  a  point  free  from  these  thickenings  of  the  tendinous 
sheaths,  and  this  necessitates  seeking  another  cause,  to  which 
the  normal  anatomy  of  the  part  will  guide  us. 

If  the  skin  and  subcutaneous  cellular  tissue  be  carefully 
reflected  from  the  palmar  fascia  of  a  normal  hand,  and  an 
opening  made  in  it  at  the  level  of  the  metacarpo-phalangeal 
joint,  the  close  relation  of  the  fascia  to  the  subjacent  flexor 
tendons  will  be  clear.  The  special  arrangement  of  the 
synovial  sheaths  of  the  fingers  is  here  of  importance,  and,  as 
is  well  known,  in  the  majority  of  cases,  the  tendinous  sheaths 
of  the  three  lesser  fingers  are  limited  by  ads  de  sac  at  the 
metacarpo-phalangeal  line,  and  at  this  spot  the  vinculo, 
vaginalia  tendinum  are  attached  to  the  tendons,  and  on 
moving  the  fingers,  there  will  be  seen  to  move  with  them 
delicate  vascular  folds,  the  so-called  mesotena,  or  synovial 
fringes.  In  flexion  and  extension  these  processes  are 
pushed  up  and  down,  and  there  can  be  little  doubt  that  any 
change  of  these  parts  interfering  with  the  free  motion  of  the 
tendons,  will  produce  obstruction  to  flexion  and  extension, 
and  especially  will  this  be  the  case  at  a  certain  stage  of 
motion,  when  the  synovial  folds  pass  underneath  the  trans- 
verse process  of  the  palmar  fascia.  In  extension,  the 
synovial  sheaths  pass  decidedly  under  this  fascia,  in  flexion, 
they  pass  towards  the  wrist,  and  this  can  be  seen  by  making 
openings  in  the  palmar  fascia,  so  that  one  can  understand 
that,  partly  through  thickening  in  the  transverse  process  of 
the  palmar  fascia,  partly  through  a  rolling  up  or  displace- 


JERK,    SNAP,    OR    SPRING    FINGER.  2>1() 

ment  of  the  processes  of  the  synovial  sheaths,  a  block  in 
motion  may  occur,  and  it  is  just  at  this  precise  spot  that  the 
hindrance  and  swelling  have  often  been  observed.  It  would 
thus  appear  that  it  is  not  in  the  joints,  nor  in  the  phalangeal 
portions  of  the  tendinous  sheaths,  that  this  obstruction  is  to 
be  sought,  as  a  rule. 

Moreover,  the  manner  in  which  some  of  the  cases  arose 
lends  support  to  this  view.  As  sometimes  through  injury, 
and  at  others  without,  but  accompanied  with  rheumatism, 
a  circumscribed  nodular  swelling,  which  may  have  been 
either  an  intra-vaginal  blood  extravasation,  or  a  little  rent 
in  the  affected  portion  of  the  palmar  fascia,  with  subsequent 
thickening,  occurred ;  and  as  in  others,  pressure-contusion 
or  sprain  may  have  given  rise  to  changes  which  produced 
a  narrowing  at  the  spot  mentioned,  the  joint  theory  may  be 
excluded,  though  any  thickening  or  irregularity  of  the 
tendon,  or  its  serous  sheath,  would  produce  the  symptoms ; 
and  the  more  the  thickening  of  the  fascia  or  tendon,  the 
more  marked  will  be  the  hindrance  to  motion  at  a  particular 
phase. 

In  the  thumb,  as  previously  remarked,  the  anatomical 
conditions  are  different,  as  the  synovial  sheath  of  the 
flexor  longus  pollicis  passes  without  interruption  into  the 
common  sheath.  In  some  of  the  cases,  the  injury  or 
disease  seemed  at  first  to  affect  the  joint  as  well  as  the 
tendon ;  but  after  treatment  the  joint  motions  became  free, 
while  the  hindrance  to  flexion  and  extension  could  be  felt 
on  the  palmar  aspect  of  the  thumb  at  the  metacarpo- 
phalangeal joint.  In  some  cases,  a  thickening  could  be  felt 
and  great  pain  at  this  spot,  while  the  other  joints  were  free, 
so  that  a  circumscribed  affection  at  this  spot  must  have  been 
the  cause.  A  thickening  and  consequent  narrowing  of  the 
canal  at  this  spot  seems  to  be  the  only  explanation ;  but 
whether  it  was  due  to  thickening  of  the  synovial  capsule,  or 


38o 


BODILY    DEFORMITIES. 


of  the  ligaments,  or  of  the  synovial  process,  cannot  be 
decided  without  direct  examination.  It  would,  therefore, 
appear  that  not  only  is  there  a  disproportion  at  a  certain 
spot  between  the  size  of  the  tendon  and  its  canal,  i.e.  a 
stricture  of  the  tendinous  sheath,  on  the  one  hand,  with  or 
without  circumscribed  thickening  of  the  tendon  on  the  other; 
but  that  often  it  may  be  due  merely  to  a  thickening  of  the 
vaginal  processes,  which  become  stopped  as  they  pass  under 
the  transverse  bands  of  the  palmar  fascia ;  and  there  may 
also  be  a  thickening  of  the  latter,  while  the 
synovial  processes  remain  intact,  while  in  the 
thumb,  the  mischief  occurs  at  the  metacarpo- 
phalangeal joint. 

Pathogenesis.  —  How  these  various 
changes  are  produced  one  cannot  positively 
say,  but  that  they  follow  injuries,  and  occur 
in  rheumatic  subjects,  there  is  no  question. 
It  may  be  that  a  rupture  of  some  of  the 
tendinous  fibres  may  produce  thickening,  or 
it  may  be  that  the  injury  or  disease  may 
produce  tendo-vaginitis,  and  so  cause  en- 
largement of  the  synovial  fringes.  It  may 
be  that  small  ganglia  are  formed  in  these 
tendons,  and  I  have,  on  two  or  three  occa- 
sions, opened  such,  on  the  palmar  aspect  of  the  fingers.  In 
one  case  (see  Fig.  190)  it  was  so  large  that  flexion  was 
impossible  until  the  sac  had  been  emptied.  There  may  be 
partial  adhesions  between  the  tendons  and  its  sheath  at 
certain  spots,  and  after  certain  injuries  or  diseases,  and 
again,  it  may  be,  that  in  elderly  people,  small  sesamoid 
cartilages  may  form  in  some  of  these  tendons,  as  we  find 
them  occasionally  in  the  peroneal  tendons  and  elsewhere. 
Roser's  view  that  this  affection  is  due  to  a  thickening  at 
the  place  where  the  profundus  pierces  the  sublimis  would 


Fig.  190. — Gang 
lion  of  flexor  ten 
dons  of  index. 


JERK,    SNAP,    OR    SPRING    FINGER.  38 1 

appear  to  be  a  rare  cause,  as  the  seat  of  obstruction  is,  as 
before  said,  found  higher  up,  and  seeing  that  such  an 
anatomical  condition  is  absent  in  the  thumb,  unless  we 
regard  the  passage  of  the  long  tendon  through  the  tendons 
of  the  short  as  analogous  to  it,  we  must,  in  any  case  in 
which  obstruction  is  felt  to  be  at  this  spot,  look  rather  to 
the  synovial  folds  attaching  the  tendons  to  the  phalanges  as 
more  likely  to  be  affected,  than  the  tendons  themselves. 

Prognosis.— This  will  depend  upon  the  cause  and  upon 
the  time  at  which  the  case  comes  under  observation.  In 
traumatic  cases,  blood  extravasations  may  become  absorbed, 
and  the  hindrance  to  motion  vanish.  Partial  rupture  of 
tendons  may  unite  without  excessive  effusion ;  or,  if  this 
have  formed,  it  may  become  absorbed  and  the  malady 
disappear.  In  rheumatic  cases,  the  prognosis  is  not  usually 
very  satisfactory.  In  cases  of  tendo-vaginitis,  whether  trau- 
matic, primary,  or  secondary  to  tubercular  affections  of  the 
phalanges  or  their  joints,  the  prognosis  will  depend  upon  the 
amount  of  mischief  which  has  occurred  at  the  time  the  case 
is  brought  under  observation. 

Treatment.— Patients  suffering  from  this  affection,  seeing 
that  it  interferes  with  the  use  of  the  members  by  which  most 
of  us  earn  our  bread,  are  most  anxious  for  relief,  for  it  is 
not  only  the  affected  digit,  but  the  whole  hand  which  is 
hampered  in  its  usefulness.  If  a  sprain  or  hurt  have  pro- 
duced it,  or  have  caused  tearing  of  tendon  fibres,  cold 
applications,  and  fixing  the  fingers  in  flexion  until  union  has 
taken  place,  should  be  adopted,  and  when  tenderness  of  the 
part  has  subsided,  frictions  and  passive  motion  may  be 
resorted  to ;  but  in  such  cases,  thickenings  of  the  synovial 
fringes,  or  fibrous  deposit,  or  adhesions,  are  apt  to  form. 
Elastic  compression  and  massage  are  of  service,  as  was 
proved  in  my  cases.  In  rheumatic  cases,  a  similar  treatment, 
combined  with  medical  means,  must  be  adopted ;  but  if  in 


382  BODILY    DEFORMITIES 

any  of  these  cases,  after  a  good  trial  has  been  given  to  the 
methods  mentioned,  the  hindrance  should  persist,  and  a 
thickening  or  nodule  be  clearly  felt  to  produce  the  obstruc- 
tion and  pain  at  a  particular  spot,  this  must  be  dealt  with 
by  operation.  If  it  be  a  ganglion,  subcutaneous  puncture 
with  friction  and  pressure  may  cure  it ;  but  if  there  be 
callosities,  or  fibrous  or  connective  tissue  thickenings,  a 
longitudinal  incision  through  the  thickened  spot  should  be 
carefully  made,  the  skin  held  apart,  the  adhesions  separated 
and  circumscribed  thickenings  excised.  Faradization,  strong, 
voluntary  or  passive  motions  of  the  tendons,  if  not  too 
painful,  and  if  painful,  under  an  anaesthetic,  may  be  resorted 
to,  and  succeeded  in  some  of  Berger's  cases.  This  plan 
may  be  adopted  either  before  or  after  incision,  if  necessary. 
Antiseptic  precautions  should  be  used  by  those  who  think 
them  desirable. 


ANCHYLOSIS.  3^3 


PART   V. 

ANCHYLOSIS    AND    OTHER    DEFORMITIES. 


CHAPTER   XXIV. 

ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS. 

Definition. — This  deformity  consists  of  stiffness  of  a 
greater  or  less  extent  and  resistance  in  a  joint  or  its  neigh- 
bourhood,  and   is   commonly  the   result    of  inflammatory 

changes. 

Synonyms. — Greek,  ayKvXog  crooked  or  hooked,  ayxihrn 
bent:  English,  stiff-joint,  fixed  joint :  French,  roideur  articu- 
laire ;  German,  Geknkverwachswig. 

Varieties. — These  are  the  osseous  and  fibrous,  the  former 
being  termed  true  anchylosis  and  the  latter  fialse.  Anchylosis 
may  also  be  extra  or  intra- articular,  and  either  the  true  or 
false  forms  may  be  chiefly  peripheral,  or  mainly  central. 
Complex  or  co?nbined  anchylosis  is  that  form  in  which 
pathological  dislocations,  whether  complete  or  partial, 
occur.  Spurious  anchylosis  is  due  to  stiffness  of  the 
muscles,  tendons,  and  ligaments,  without  pathological 
change,  and  is  generally  caused  by  long  continued  rest  in 
one  position.  It  may  also  be  due  to  cicatricial  contractions 
of  the  skin  and  subcutaneous  tissue,  as  after  burns,  &c, 
or  to  extra-articular  exostoses.  Osseous  and  fibrous  anchy- 
losis may  be  partial  or  complete.  Osseous  anchylosis 
is  also  termed  synostosis.     Either  form  may  be  congenital  or 


3^4 


BODILY    DEFORMITIES. 


acquired,  the  former  being  rare.  In  congenital  anchylosis 
the  joint  surfaces  are  generally  more  or  less  deficient  or 
absent.  Fibrous  anchylosis  is  far  commoner  than  bony, 
and,  as  a  rule,  more  frequently  met  with  in  young,  than 
elderly  people,  as  joint  disease,  not  rheumatic  or  gouty, 
is  more  common  in  them. 

Ca/uses. — Diseases  of  the  joint 
producing,  or  originating  in  inflam- 
mation, whether  traumatic  or 
spontaneous,  are  the  most  common 
causes.  The  inflammation  may 
have  a  tubercular,  or  strumous, 
rheumatic,  gouty,  syphilitic,  septic- 
emic, scarlatinal,  puerperal,  or 
nervous  origin.  Gonorrhceal  rheu- 
matism is  also  a  somewhat  dan- 
gerous cause  of  the  affection.  Long 
continued  pressure  will,  of  itself, 
produce  erosion  of  cartilages,  and 
bony  anchylosis,  as  in  severe  cases 
of  lateral  curvature,  and  in  some 
old  and  bad  cases  of  varus  or  flat 
foot.  Inflammatory  oedema  around 
joints,  if  it  become  organized,  will 
lead  to  the  extra-articular  forms  of 
the  malady.  Long  continued  rest 
or  fixation  in  a  particular  position 
will  produce  considerable  stiffness 
of  joints,  and  though  some  French  writers  are  inclined 
to  question  this,  no  experienced  surgeon  can,  I  think,  doubt 
its  occurrence.  This  variety  is  usually  of  the  spurious 
form,  i.e.,  due  to  stiffness  of  joints  and  ligaments  without 
marked  pathological  change,  though  undoubted  cases  of 
fibrous  anchylosis  have  occurred  from  this   cause,   and,  as 


Fig.  191.  —  Severe  false 
anchylosis  of  hip  and  knee 
after  rheumatism,  which  was 
successfully  straightened  at 
one  sitting  by  manual  force. 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.         385 

will  be  presently  seen,  a  case  of  bony  union  has  been  re- 
corded by  Teissier.  Sir  James  Paget*  and  Butlinf  have 
drawn  attention  to  cases  of  this  nature,  as  have  also  several 
German  and  some  French  authors,  among  whom  may  be 
mentioned  Menzel,!  Reyher,§  and  Teissier,||  and  Jacob- 
son,1T  quoting  Teissier,says  that  long  continued  rest  causes : — 
1.  "Escape  of  blood  or  serum  into  the  cavity,  into  the  sub- 
synovial  cellular  tissue,  or  into  the  soft  parts  outside  the 
joint.  2.  Vascular  injections  of  the  synovial  fringes,  with 
formation  of  false  membranes.  3.  Alterations  of  the 
cartilage,  e.g.,  swelling,  softening,  and  erosion.  4.  Anchy- 
losis ;  this  is  shown  to  be  not  only  frequently  fibro-cellular, 
but  in  one  case,  at  least,  where  the  thigh  was  amputated  for 
non-union  of  a  fractured  femur  after  twenty-two  months  of 
extension  and  immobility,  it  is  proved  that  actual  fusion  of  con- 
tiguous articular  surfaces  may  take  place."  Teissier  thought 
that  prolonged  immobility  of  a  joint  caused  a  suppression  of 
the  synovia  and  engorgement  of  the  articular  structures, 
and  these  observations  are  confirmed  by  Menzel.  Reyher 
states  that  in  cases  where  immobility  has  been  occasionally 
interrupted,  ulceration  of  the  joint  cartilages  may  occur. 
It  must,  however,  be  borne  in  mind,  as  pointed  out  by 
Jacobson,  that  there  are  certain  sources  of  fallacy  which 
must  not  be  overlooked,  e.g.,  in  cases  where  prolonged  rest 
has  been  necessitated,  by  an  injury  to  a  limb,  such  as 
fracture,  or  dislocation,  the  primary  injury  may  have  set  up 
articular  mischief  which  was  unnoticed  at  the  time,  and  I 
would  add  that  there  need  not  have  been  original  injury 
to  the  joint,  but  changes   may  have   extended  to  it  along 

*   "Clinical  Lectures,"  Second  Edition,  1879,  p.  213. 
t  Path.  Soc.  Trans.,  Vol.  25. 
X  Arch,  fur  Klin.  Chir.,  B.  12. 
§  Deutsche  Zeitschrift  fur  Chir.,  B.  3. 
1)    Gaz.  Med.,  1841. 

^   "Hilton's  Lectures  on  Rest  and  Pain,"  Third  Edition,  p.  321. 

C   C 


3S6 


BODILY    DEFORMITIES. 


the  periosteal  or  medullary  vessels,  for  we  know  that  in 
some  eases  of  fracture  of  the  femur,  or  even  of  osteotomy 
at  the  junction  of  the  middle  and  lower  femoral  thirds,  even 
after  plaster-of-Paris  is  at  once  applied,  a  temporary  effusion 
into  the  joint  cavity  may  occur,  and  though  this  is  usually 


Fig.  i92.-Rheumatic  anchylosis  of  knees.     Inflammatory  mischief  being  present 
and  other  joints  affected,  nothing  was  done. 

absorbed  there  may,  in  individual  cases,  be  some  con- 
stitutional or  local  predisposition  to  a  continuance  of  inflam- 
matory action,  leading  to  fibrous  or  osseous  anchylosis. 
Dr  Bruce*  has  shown  the  proneness  of  certain  joint 
*  Path.  Soc.   Trans.,  Vol.  20. 


ANCHYLOSIS   AND    i\i:i  Dl  I  ED    DISLOCATIONS.        387 

cartilages,  after  young  adult  life,  to  show  signs  of  commenc- 
ing degeneration. 

Pathology.— The  fibrous  form  is  due  to  the  effusion  of 
inflammatory  products  either  around  or  into  the  interior  of 
joints,  or  both,    and  to    the   organization    of    tin's  effused 


FlGS.  193,  194,  and  195. — Scrofulous  bony  ani  tylosis  after  morbis  coxse.  Lower 
Umbar  cure  1  Pott's  disease.  The  left  hand  figure  shews  the  patient  before  operation 
Standing  in  her  hoot  ;  the  middle  figure  represents  her  Standing  in  ordinary  hoots  on 
the  affected  leg  ;  the  right  hand  figure  i.s  how  she  was  six  weeks  after  operation. 

material.  Lymph  exudes  into  the  connective  structures  in 
and  about  the  joint  and  along  the  sheaths  of  the  tendons 
and  muscles,  and  the  parts  are  matted  together  in  a  defective 
position,  so  that  the  movements  are  consequently  impaired. 
In  the  intra-articular  form,  the  cartilages  are  united  by 
adhesions  which  sometimes  become  firm  and  strong,  and 

c  c  2 


388  BODILY    DEFORMITIES. 

cases  are  known  in  which  spicules  of  bone  have  been  found 
in  the  fibrous  bands,  external  or  internal  to  the  joint,  and, 
in  some  cases  of  severe  injury  or  inflammation,  the  fibrous 
tissue  may  organize  into  bone,  but  a  good  deal  depends 
upon  the  manner  in  which  the  joint  has  been  treated.  If 
absolute  rest,  with  other  proper  methods,  have  been  adopted 
in  an  early  stage,  these  adhesions  are  not  firm,  but  if  the 
joint  have  been  allowed  to  become  fixed  in  the  usual  flexed 
position,  the  articular  surfaces  are  no  longer  in  their  proper 
relations,  and  the  resulting  contraction  of  tendons,  ligaments, 
and  fascia  about  the  joint  are  generally  of  a  more  obstinate 
nature.  This  form  of  anchylosis  may  also  be  due  to 
adhesions  between  the  walls  of  the  synovial  sac,  which  are 
formed  in  the  direction  to  which  the  limb  is  bent.  It  may 
also  be  caused  by  cicatricial  contraction  of  the  joint- 
capsule  and  surrounding  ligaments. 

The  bony  form  is  due  to  erosion  of  the  joint  cartilages 
and  the  junction  of  the  articular  ends  of  the  neighbouring 
bones,  and  though,  in  some  rare  cases,  this  may  occur  after 
dry  inflammation  of  the  joint,  the  rule  is  for  the  inflam- 
mation to  end  in  the  formation  of  pus  with  destruction  of 
the  joint  structures  and  the  gradual  disintegration,  elimina- 
tion, or  absorption  of  necrosed  portions  of  cartilage  and 
bony  debris,  before  synostosis  occurs.  The  position  in 
which  bony  union  takes  place  will  vary  according  to  the 
manner  in  which  the  limb  has  been  treated.  In  some  of 
the  cases,  impediment  to  motion  is  due  to  unevenness  of 
the  remaining  cartilaginous  surfaces,  and,  in  others,  to 
stalactites  of  bone  formed  in  the  erosion-places  between 
the  cartilage  which  has  been  spared.  Another  cause  of 
bony  anchylosis  is  in  the  ossification  of  articular  cartilages, 
and  Volkmann  has  described  this  cartilaginous  anchylosis, 
which  occurs  commonly  after  suppurative  subacute  coxitis, 
in  young    people,   and    it   may   also   occur    in   the  knee, 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.         389 

elbow,  or  ankle.  Billroth  considers  the  name  well  chosen, 
because  the  cartilage  remains  long  intact.  In  some  cases 
of  rheumatic  arthritis  and  arthritis  deformans,  bony  deposits 
form  in  the  joint  and  hinder  its  movements.  These  are 
mechanical  obstructions  of  a  different  kind,  as  the  limitation 
of  motion  is  prevented  by  the  meeting  or  locking  of  these 
new  processes,  and  not  to  the  union  of  adjoining  articular 

surfaces. 

It  will  be  well  to  separately  describe  the  changes  as  they 
affect  each  articular  constituent,  commencing  with  the  bones. 
If  an  average  joint,  i.e.,  one  not  in  the  early  or  in  the  later 
stage,  be  examined,  one  finds  that  the  articular  surfaces  are 
roughened,  dry,  deformed,  and  more  or  less  closely  united, 
and  very  often  the  cartilages  and  fibro-cartilages  are  swollen, 
softened,   and    velvety,    and    have    disappeared   in  parts. 
Sometimes    there    are    isolated  sequestra,  which   may  be 
undergoing  absorption,  or  may  even  ossify  and  assist  in  the 
anchylosis.     The   bony  articular    ends    are   more   or  less 
deformed  and  displaced,  and  if  the  malady  have  been  un- 
treated, there  will  be   a  partial  displacement  of  the  articular 
ends,  according   to  the   direction  of  the  disease  and  the 
power  of  the  opposing  muscles.     In  the  knee,  which  is  so 
commonly  affected,  the  tibia  is   often  displaced  back  and 
outwards,    and   its   articular   end    is   in   contact   with  the 
posterior  part  of  the  femoral  condyles,  which  form  a  marked 
projection    anteriorly.      The    transverse   diameter  of   the 
lower  end   of  the  femur  is  relatively,  and  often  absolutely, 
diminished,    and   the    femoral  tuberosities,    to    which  the 
muscles  are  attached,  are  atrophied.     The  long  diameter 
of  the  lower  end  of  the  femur  is  increased,  as  was  first 
pointed  out  by  Bonnet,*  and  afterwards  by  Gosselin,t  and 
this  has  been  recently  studied  by  Volkmann.t      In   such 

*  "  Traite  des  Sections  Tendineuses." 

t  Clinique  de  Vhopital  de  la  Charite,  T.  2,  p    168. 

%  Berliner  Klin.  Woch.,  1874,  p.  629. 


39°  BODILY    DEFORMITIES. 

cases  that  portion  of  the  femur,  which,  in  consequence  of 
flexion  of  the  leg,  has  been  relieved  from  the  pressure  of 
the  tibia  and  of  the  body-weight,  increases  in  length,  so 
that  a  longitudinal  section  through  it  forms  half  an  ellipse. 
If  this  be  not  borne  in  mind,  such  a  case  may  be  mistaken 
for  a  dislocation  backwards  of  the  tibia,  and  a  glance  at 
the  accompanying  figure  will  suffice  to  show  that  reduction 
is  next  to  impossible.     The  tibia  is  often  connected  to  the 


Fig.  196. — Diagram,  after  Volkmann,  to  shew  the  lengthening  of  the  lower  end  of 
the  femur  in  chronic  arthritis. 


femur  by  fibrous  bands.     These  are  sometimes  soft  and  at 
others  very  firm. 

At  a  later  stage,  or  in  severe  and  acute  cases  at  an  earlier 
period,  the  bones  are  fused,  or  connected  by  an  intermediate 
layer  of  bone.  Ordinarily,  this  ossific  change  proceeds 
from  the  periphery  to  the  centre,  and.  if  the  joint  be 
ginglymoid,  the  process  commences  usually  at  the  con- 
vexity, and  later  on  is  most  active  at  the  concavity,  so  that 
when  the  pathological  process  is  complete,  the  osseous 
tissue  is  more  compact  in  the  latter  situation.  The  laminae 
of  the  epiphysial  spongy  tissue  are  displaced  towards  the 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS. 


391 


periphery,  and  form  a  compact  layer,  joining  the  bones,  and 
in  some  cases  the  medullary  canals  of  the  two  bones  are 
continuous  ;  but  this  is  not  the  rule,  as  commonly  there 
are  distinct  traces  of  demarcation  between  the  two  bones. 
In  some  cases  the  union  is  merely  by  stalactitic  processes. 

The  patella  may  be  displaced  or  firmly  adherent  to  the 
condyle,  and  it  is  most  commonly  joined 
to  the  external  condyle,  but  sometimes  to 
the  internal,  and  occasionally  it  is  fixed 
to  the  inter-condyloid  notch.  Foucher* 
relates  a  case  in  which  it  was  united  to 
the  external  condyle  by  bone  along  its 
upper  half,  and  its  apex  was  joined  to 
the  tibia  by  an  osteo-cartilaginous  bridge. 
Sometimes  this  bone  undergoes  rotation, 
so  that  one  of  its  borders  is  prominent, 
and  its  articular  surfaces  inclined  ante- 
riorly. In  other  less  common  cases  the 
adhesions  are  around  the  patella,  and 
form  the  chief  obstacle  to  movements ; 
and  these  cases,  in  which  the  anchylosis 
is  due  solely  to  the  patella,  appear  to  be 
oftenest  due  to  injury  or  gonorrheal 
rheumatism.  In  scrofulous  and  rheu- 
matic cases,  the  new  bony  tissue  is  more 
friable  or  flexible,  as  a  rule,  and  in  some 
cases  the  cancellous  spaces  are  enlarged, 
while  in  others  they  are  condensed. 

The  synovial  membrane  is  always  more  or  less  thickened, 
especially  in  chronic  inflammations,  and  is  a  powerful  factor 
in  the  immobility  of  the  bones.  The  degree  of  the  thicken- 
ing varies,  being  sometimes  universal,  at  others  only  in 
patches.  In  the  shoulder,  the  sub  glenoid  fold  is  that  which 
*  Bulk' in  de  la  Soc.  Anat.,  1855,  p.  473. 


Fig.  197.  —  To 
shew  the  position  of 
the  bones  in  a  case 
of  bony  anct^losis 
at  the  knee. 


392  BODILY    DEFORMITIES. 

prevents  abduction  of  the  arm,  and  in  the  knee  the  supra- 
patella  pouch  is  folded  and  adherent.  Duret*  compares 
the  evolution  of  the  fibrino-plastic  synovial  products  due  to 
arthritis  from  colds,  to  the  false  membranes  of  fibrinous 
pleurisy,  and  points  out  the  powerful  resistance  that  these 
adhesions  ultimately  form.  Hueterf  states  that  the  firmness 
of  the  marginal  adhesions  is  opposed  by  the  softness  of  the 
central  ones,  which  are  due  to  delicate  vascular  prolongations 
from  the  granulation  tissue  formed  at  the  expense  of  the 
cartilage,  the  peripheral  adhesions  being  formed  by  the  syno- 
vial and  peri-synovial  tissues,  which  render  them  always 
strong. 

The  ligaments  are  changed  in  structure,  and  often  in 
direction,  and  in  some  cases  have  undergone  bony  change. 
At  first  there  is  a  sero-gelatinous  infiltration  in  the  intersti- 
tial cellular  tissue  which  invades  the  fibrous  laminae;  causing 
them  to  swell  and  lose  their  glistening  aspect.  They 
become  soft  and  transparent,  and,  microscopically,  show 
abundant  cell  proliferation,  so  that  a  tissue  is  formed  similar 
to  cicatricial  tissue.  In  dissections,  it  is  often  difficult  to 
recognize  them  and  make  out  their  attachments.  The 
thickening  of  some  ligaments,  and  especially  of  the  posterior 
ligament  of  the  knee,  and  the  anterior  of  the  elbow,  is  due 
to  changes  in  the  ligament  itself  and  to  its  synovial  lining, 
as  well  as  to  changes  in  the  peri-articular  cellular  tissue. 
Sometimes  ligamentous  changes  are  slight  while  the  joint 
functions  are  almost  abolished,  so  that  while  ligaments  may 
be  normal  to  the  naked  eye,  attempts  at  rectification  show 
them  to  be  very  resisting,  or  to  become  ruptured.  The 
ligaments,  as  already  stated,  may  also  ossify,  forming  iso- 
lated plates,  stalactitic  growths,  or  dense  masses  of  bone ; 
and  veterinary  surgeons  are  familiar  with  a  form  of  anchy- 

*  Bulletin  de  la  Soc.  Anal.,  1872. 

T  Klinik  der  Gelenkkrankheiten^  B.  2,  S.  270,  1876. 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.         393 

losis  forming  a  ring  around  the  articulation.  Movement  is 
of  course  impossible  in  such  cases,  and  if  a  vertical  section 
be  made  through  a  joint  anchylosed  peripherally,  it  will 
commonly  be  found  that  the  other  joint  structures  are 
intact,  or  there  may  be  present  those  changes  in  the 
synovial  membrane  due  to  prolonged  immobility. 

The  extra-articular  structures  are  also  involved.  The 
cellular  tissue  about  a  joint,  especially  in  front  of  the  elbow 
and  back  of  the  knee,  may  become  thickened  and  fuse  with 
the  adjoining  ligament  so  as  to  form  a  sort  of  fibrous  callus  ; 
and  it  must  be  borne  in  mind  that  this  tissue  is  like  cicatri- 
cial tissue,  and,  being  but  little  extensile,  it  tears  or  breaks. 
The  tendons  are  often  united  to  their  sheaths,  and  these  are 
glued  to  the  surrounding  joint  structures.  The  muscles  are 
altered  in  structure,  size,  and  shape.  They  are  wasted, 
contracted,  and  fattily  degenerated ;  but  in  cases  where 
slight  motion  remains,  they  may  be  normal,  or  some  part  of 
the  degenerated  muscles  may  have  retained  a  portion  of 
their  elasticity  and  extensibility,  and  it  is  to  these  that  the 
rarity  of  muscular  rupture,  in  forcible  reduction  in  the  more 
fragile  forms  of  bony  anchylosis,  is  due.  The  aponeuroses 
around  joints  become  fibrinously  degenerated  and  con- 
tracted, and  this  is  especially  the  case  with  the  capsule  and 
expansions  in,  around,  and  at  the  sides  of  the  knee.  The 
subcutaneous  cellular  tissue  is  thickened,  indurated,  and 
closely  adherent  to  the  skin,  and  to  the  deep  fascia,  so  that 
all  mobility  has  frequently  disappeared  from  it.  The  skin  is 
stretched  and  thinned,  and  sometimes  traversed  by  dilated 
veins. 

The  vessels  and  nerves  are  most  affected  in  the  ginglymoid 
joints,  and  in  the  first  instance  they  are  relaxed,  in  conse- 
quence of  the  flexion  of  the  limb  ;  they  then  become  re- 
tracted, and  sometimes  to  such  an  extent  that  any  attempt 
to  straighten  the  limb  results  in  their  rupture,  but  this  is 


394  BODILY    DEFORMITIES. 

rare.  They  may  be  tortuous,  and  then  extension  does  not 
harm  them,  unless  their  walls  have  become  degenerated. 
In  some  rare  cases,  as  in  a  case  of  knee  anchylosis  related  by 
Chassaignac,*  the  popliteal  vessels  were  away  from  the  joint, 
and  were  strongly  stretched  in  a  straight  line,  so  that  they 
would  surely  have  been  ruptured  in  attempts  at  extension. 

If  anchylosis  be  acquired  at  an  early  age,  the  develop- 
ment of  the  bones  forming  the  joint  may  be  interfered  with, 
but  usually  there  is  no  great  change  in  their  length,  though 
the  limb  is  less  developed,  and  this  may  probably  be  due  to 
lack  of  use.  When  the  epiphyses  are  affected,  however, 
arrest  of  development  occurs,  leading  to  inequality  of  the 
length  of  the  bones  of  the  affected  limb,  and  to  correspond- 
ing non-development  of  all  its  structures. 

The  chief  pathological  changes  have  now  been  given,  it 
only  remains  to  recollect  that  all  may  be  present,  but  more 
commonly  only  some  of  them  are  met  with,  so  that  some- 
times, only  peripheral  lesions  occur  ;  at  other  times,  synovial 
and  articular  surfaces  are  affected,  and  this  has  led  to 
varying  classifications  ;  but  it  seems  to  me  that  for  practical 
purposes  one  should  recognize  not  only  fibrous  and  bony 
anchylosis,  but  complete  and  incomplete  union.  The  latter 
may  be  loose  or  firm,  and  is  diagnosed  by  the  amount  of 
movement  permitted.  The  following  arrangement  is  a 
serviceable  one  : — 

i.  Anchylosis  may  be  co7?iplete  and  loose,  and  the 
pathological  changes  in  such  cases  are  various.  There 
may  be  osseous  or  fibrous  bands,  thickening  and  partial 
adhesion  of  the  synovial  membranes,  thickening  and  in- 
duration of  the  ligaments,  or  retraction  of  one  or  more 
ligamentous  bands,  and  a  slight  deformity  of  the  car- 
tilaginous surfaces.  The  extra-articular  structures  are 
little  or  not  at  all  changed. 

*  Bulletin  de  la  Soc.  Anat.,  1839. 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.         395 

2.  Anchylosis  may  be  incomplete  and  firm.  The  patho- 
logical changes  will  depend  upon  the  nature  and  cause  of 
the  pre-existing  joint  mischief.  There  maybe  a  firm,  dense, 
fibrous  intra-articular  band  or  bands,  or  an  extensive  peri- 
pheral induration,  with  ligamentous  changes  or  alteration  in 
the  joint  surfaces.  The  extra-articular  structures  are  more 
or  less  changed. 

3.  The  anchylosis  may  be  complete,  and  may  be  fibrous 
or  bony.  If  the  former,  the  union  is  usually  very  firm  ;  if 
bony,  the  union  may  be  central,  peripheral,  or  entire.  The 
articular  cavity  has  disappeared,  and  there  is  a  peripheral 
sclerosis  of  the  soft  parts  which  often  extends  to  the 
integuments.     Muscular  degeneration  is  always  present. 

The  processes  preceding  anchylosis,  and  determining  the 
direction  in  which  the  limb  may  be  fixed,  require  a  little 
consideration.  The  pathological  changes  have  sufficiently 
been  given,  but  the  position  of  the  limb  is  determined, 
partly  by  the  mechanical  construction  of  the  joint,  and 
partly  by  muscular  action.  In  the  shoulder,  anchylosis 
is  almost  always  observed  with  the  arm  in  a  line  by  the  side, 
and  for  the  reason  that  the  weight  of  the  limb  relieves 
inter-articular  pressure,  because  the  muscles  passing  from 
the  trunk  to  the  humerus  before  and  behind  the  joint  are 
about  equally  balanced,  so  that  there  is  but  little  dis- 
placement, and,  if  so,  this  is  usually  in  the  direction 
towards  the  mid-line.  At  the  elbow,  flexion  is  determined 
by  the  biceps  and  brachialis  anticus,  though,  in  some  cases, 
anchylosis  occurs  in  a  straight  line,  and  then  is  due  to  this 
position  being  the  easiest  for  the  patient ;  and  it  will  be 
found  in  such  cases,  that  the  anterior  part  of  the  joint  is 
more  involved.  At  the  wrist,  the  hand  is  fixed  usually  in 
a  position  between  flexion  and  extension.  At  the  /tip,  the 
muscles  passing  along  the  front  and  inner  side  of  the  thigh 
produce  adduction   and   flexion,    the  position    most  com- 


396  BODILY    DEFORMITIES. 

monly  met  with,  and  which  must,  I  think,  be  due  not 
merely  to  the  supposed  predominant  action  of  these 
muscles,  but  also  to  the  relief  and  relaxation  this  position 
gives  to  the  articular  structures. 

In  the  knee,  flexion  and  rotation  of  the  leg,  displacement 
of  the  patella,  and  partial  dislocation  of  the  tibia,  are  often 
met  with.  Semi-flexion  and  rotation,  commonly  outwards, 
but  sometimes  inwards,  results,  if  the  limb  have  been  left  to 
itself,  for  in  this  position  the  ligaments  are  most  relaxed, 
and  the  articular  cavity  acquires  its  greatest  capacity. 
Tibial  displacement  is  common,  and  usually  occurs  back- 
wards, or  backwards  and  outwards,  though  the  bone  may 
be  displaced  forwards  or  laterally,  this  being  rare.  Bauer* 
describes  a  case  of  retro-curvation  due  to  osseous  anchy- 
losis of  the  right  knee  following  a  punctured  wound. 
Grant,  of  Canada,  records  a  similar  case,  the  specimen  is 
in  the  St.  Louis  Museum.  Albert  has  also  related  some 
interesting  cases,  and  I  have  photographs  of  three  interest- 
ing cases,  in  one  of  which  the  malformation  was  due  to 
tabetic  arthritis,  in  one  to  rheumatic  arthritis,  and  in 
another  to  gout.  These  are  instances  of  backward  dislo- 
cation, in  which  an  angle  open  in  front  is  formed  at  the 
knee.  A  similar  condition,  the  result  of  paralysis,  is 
figured  in  the  next  chapter.  This  sub-luxation  is  due  to 
the  flexors  being  no  longer  counter-balanced  by  the 
extensors,  so  that  they  draw  the  upper  end  of  the  tibia 
behind  the  femur,  and  the  mutual  pressure  of  the  bones 
alters  the  shape  of  the  articular  surfaces,  so  that  they  no 
longer  accurately  correspond.  But  in  som'e  cases,  sub- 
luxation is  impossible,  i.e.  when  the  muscles  are  degene- 
rated or  adherent  to  their  sheaths,  or  when  numerous  firm 
fibrous  bands  unite  the  articular  surfaces  and  the  tendons 
to  their  sheaths,  and  bones.  For  luxation  to  occur,  the 
*  St.  Louis  Med.  Journal,  Vol.  6,  p.  503,  1869. 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.         397 

ligaments  must  be  changed  in  their  structure  and  shape,  so 
that  they  can  no  longer  maintain  the  bones  in  place.  The 
muscles  are  then  free  to  act,  and  as  the  extensors  are 
attached  to  the  patella,  which  becomes  fixed  to  the  exter- 
nal condyle,  the  force  of  them  is  lost  on  the  condyle,  so  that 
the  flexors,  which  pass  to  the  tibia  and  fibula,  being  no  longer 
resisted  by  the  prolongation  of  the  extensors  through  the 
ligamentum  patellae  to  that  bone,  draw  the  tibia  backwards, 
and  if  back  and  outwards,  the  latter  is  chiefly  effected  by  the 
biceps,  and  favoured  by  the  smaller  prominence  of  the  external 
condyle.  If  the  joint  surfaces  be  not  deformed,  flexion  and 
external  rotation  may  exist,  and  there  may  be  a  thickening 
of  the  tibia  at  its  upper  epiphysis,  but  sub-luxation  is 
uncommon. 

The  extra-articular  structures  in  such  cases  undergo  most 
of  the  changes  previously  described,  and  offer  serious 
obstacles  to  reduction.  The  relative  power  of  these  cir- 
cum-articular  structures  has  been  experimentally  determined 
by  Busch,*  and  he  has  shown,  by  the  results  of  experiments 
on  three  cases,  that  the  soft  parts  offer  powerful  resistance 
to  reduction,  and  that  the  skin  offers  a  greater  resistance 
than  the  flexors,  so  that  tenotomy  is  often  useless.  The 
most  important  of  the  resisting  factors  is  the  fibrous  tissue 
around  the  joint,  and  this  tears  in  attempts  at  reduction. 
This  may  also  contract  so  as  to  compress  the  vessels  and 
nerves,  leading  to  atrophic  changes  of  the  leg ;  and  this  is 
sometimes  so  strong,  that  attempts  at  reduction  may  end 
in  fracture  or  separation  of  epiphyses,  rather  than  to  its 
yielding.  At  the  knee,  this  fibrous  thickening  is  commonest 
in  the  popliteal  space,  but  sometimes  the  aponeurotic  ex- 
pansion at  the  front  and  sides  of  the  knee  becomes  indurated 
and  thickened,  and  so  resists  further  flexion,  though  tending 

*  "Beitrag    zur  Kenntniss    der    Contracturen  in  Hiift   und  Knie 
Gelenke,"  &c,  Arch,  fur  Klin.  C/rir.,  1863. 


39§  BODILY   DEFORMITIES. 

to  fix  the  limb  in  its  defective  position.  These  expansions 
are  torn  in  the  movements  of  flexion  and  extension  in 
forcible  reduction,  as  is  shown  by  the  intense  pain  com- 
plained of  by  the  patient  about  the  patella  after  the 
operation. 

At  the  ankle,  anchylosis  usually  occurs  in  the  extended 
position,  or,  in  equinus,  if  the  limb  have  been  left  to  itself. 
This  is  due  to  the  weight  of  the  anterior  portion  of  the  foot, 
and  to  the  action  of  the  gastrocnemius  and  soleus,  and 
also  to  the  fact  that  extension  relieves  the  joint  surfaces  of 
a  large  amount  of  pressure.  If  the  limb  has  been  put  up  in 
a  splint  with  a  rectangular  foot-piece,  the  anchylosis  will 
then,  of  course,  be  rectangular. 

Symptoms. — These  consist  in  more  or  less  loss  of  the 
normal  motions  of  the  affected  joint,  and  consequent 
wasting  of  the  limb.  The  limb  will  be  deformed  and 
shortened,  and  the  subject  will  walk  lame.  In  the 
fibrous  forms,  the  patient  occasionally  complains  of  pain 
after  use  of  the  limb,  and  if  the  lower  limb  be 
affected  there  will  not  only  be  shortening  of  the  limb 
and  contraction  of  its  muscles,  but  if  this  exist  for  any 
time,  and  be  uncompensated,  a  tilting  of  the  pelvis, 
followed  by  compensatory  lateral  curvature,  will  result. 
Objective  examination  shows  not  only  deformity  varying  in 
degree  and  kind,  but  also  great  restriction  to  passive  motion, 
and  alteration  in  the  shape  and  relative  position  of  the 
joint  structures.  Secondary  or  compensatory  deformities  of 
the  spine  and  pelvis  usually  result,  and  if  the  anchylosis 
have  occurred  at  an  early  age,  these  may  lead  to  aggravated 
deformity. 

Diagnosis. — The  difficulty  is  in  differentiating  the  various 
kinds  of  stiffness,  and  also  the  nature  of  the  morbid  change 
existing  in  the  joint.  Joint-stiffness  may  be  due  to  existing 
inflammatory   changes    causing   reflex  contraction    of  the 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.         399 

muscles  and  circum-articular  joint  structures.  It  may  also 
be  due  to  a  voluntary  fixation  of  the  joint,  as  in  cases  of 
hysteria  and  malingering.  Pain  on  movement  may  be  due 
to  inflammation,  or  if  the  inflammatory  process  have  sub- 
sided, it  may  be  due  to  the  stretching  of  adhesions,  or  if 
there  be  partial  dislocation,  it  may  be  caused  by  stretching 
of  the  ligaments  and  tendons.  If  an  anchylosed  joint  be 
moved  without  anaesthetics,  and  pain  be  complained  of,  the 
presumption  is  that  the  union  is  not  bony,  especially  if  the 
pain  be  felt  on  the  side  from  which  the  limb  is  being 
forced.  In  distinguishing  whether  fibrous  anchylosis  be 
chiefly  intra-  or  extra-articular,  the  character  of  the  inflam- 
mation is  of  some  service,  as  to  whether  it  has  been  acute, 
sub-acute,  chronic,  strumous,  gonorrhoea!,  &c.  In  these 
forms  the  adhesions  are  commonly  in  the  joint,  whereas  in 
rheumatic  or  gouty  cases  they  may  be  within  or  without. 
In  the  scrofulous,  tubercular,  and  in  some  severe  syphilitic 
forms,  or  after  bad  injuries  to  the  joint,  bony  anchylosis 
may  occur;  but  this  form,  it  must  be  borne  in  mind,  is  far 
less  common  than  fibrous  anchylosis.  Osseous  anchylosis 
is  commonest  in  ginglymoid  joints,  as  in  the  knee  and 
elbow.  It  is  not,  however,  very  uncommon  in  ball-and- 
socket  joints,  as  evidenced  by  the  hip  ;  but  as  this  joint  is 
so  commonly  inflamed,  and  as  some  cases  are  neglected,  or 
refuse  appropriate  treatment,  cases  of  bony  anchylosis  are 
not  very  infrequent  in  a  large  surgical  and  orthopaedic 
experience.  The  shoulder  and  jaw  are  rarely  affected  with 
bony  anchylosis,  though  the  fibrous  forms  are  not  very 
uncommon. 

Immobility  of  a  joint  does  not  of  necessity  point  to 
bony  union,  and  in  cases  of  doubt,  and  before  any  opera- 
tion is  undertaken,  an  anaesthetic  must  be  administered. 
It  will  be  found  that  in  the  firm  fibrous  forms  there  is  a 
degree  of  elasticity  not  met  with  in  bony  union.     There  is 


400  BODILY    DEFORM  [TIES. 

less  difficulty  in  examining  the  distal  joints,  such  as  the 
elbow,  wrist,  knee,  and  ankle,  than  in  the  hip  and  shoulder 
joints,  for  in  these,  the  mobility  of  the  scapula  and  lumbar 
spine,  if  not  duly  allowed  for,  add  to  the  diagnostic  diffi- 
culties. If  an  anaesthetic  be  not  given,  attempts  to  move 
the  joints  will  produce  reflex  muscular  contractions  ;  and  it 
has  been  stated  that  some  of  these  muscular  movements 
show  that  there  is  some  movement  in  the  joint,  but  it  must 
be  recollected  that  muscles  often  pass  over  more  than  the 
affected  joint,  and  that  the  patient  may  contract  such 
muscles  independently  of  there  being  any  movement  in 
the  joint.  It  is  also  stated,  that  during  percussion  the 
patient  feels  a  greater  shock  in  cases  of  bony  anchylosis. 
This  relative  symptom  is  due  to  the  absence  of  the  fibrous 
processes  between  the  joint-surfaces,  which  act  as  pads,  and 
thus  diminish  the  vibration,  whereas,  in  bony  continuity,  the 
vibrations  are  continued  upwards. 

In  examining  all  joint  cases  great  care  and  gentleness 
should  be  adopted  whether  an  anaesthetic  be  used  or  not, 
for  even  if  only  the  remains  of  active  inflammation  be 
present,  or  have  but  just  subsided,  rough  measures  may 
produce  considerable  damage,  and,  at  best,  can  only  cause 
needless  suffering.  I  have  seen  too  many  cases  in  which 
so-called  bone  and  joint-setters,  have  done  most  serious 
mischief,  by  their  ignorant  proceedings  in  such  conditions 
of  things. 

Prognosis. — This  will  depend  upon  the  joint  affected, 
upon  the  cause  and  stage  of  the  disease,  and  upon  the 
nature  of  the  material  causing  the  stiffness.  In  most 
fibrous  forms,  especially  if  there  be  no  luxation,  an  useful,  if 
not  a  perfectly  strong  limb,  may  be  hoped  for,  particularly 
if  the  general  health  be  sound  enough  to  permit  of 
attempts  at  motion  being  restored.  In  cases  complicated 
with  partial  luxation,   and    in  the    bony  forms,   operative 


ANCHYLOSIS   AND    UNREDUCED    DISLOCATIONS.        40 1 

measures  hold  out  prospects  of  considerable  relief,  and  I 
.have  operated  on  many  cases,  and  other  operations  have 
been  recorded  by  various  surgeons,  in  which  the  deformity 
was  considerably  remedied,  and  a  useful  member  restored 
to  the  patient. 

Treatment. — Though  we  have  now  only  to  deal  with 
accomplished  anchylosis,  it  may  be  well  to  remind  the  reader 
of-  certain  prophylactic  measures  necessary  in  the  earlier 
stages  of  joint  disease.  The  position  of  the  affected  part 
must  depend  upon  the  vocation  of  the  patient,  but  as  a 
general  rule,  the  hip  and  knee  should  be  fixed  in  slight 
flexion  without  adduction  or  abduction.  The  ankle  should 
be  allowed  to  become  firm  at  right  angles  to  the  leg.  The 
shoulder ;  in  consequence  of  the  great  mobility  of  the 
scapula  and  clavicle,  may  be  allowed  to  anchylose  in  a  line 
with  the  body,  or  with  the  lower  end  of  the  limb  slightly 
anterior  to  it.  The  elbow  should,  as  a  rule,  be  flexed 
enough  to  enable  the  hand  to  reach  the  mouth,  and  the 
fore-arm  should  be  mid-way  between  pronation  and  supina- 
tion. 

There  are  five  plans  which  may  be  followed  in  dealing 
with  this  deformity,  (i)  gradual  extension  by  weights  or 
instruments,  (2)  rapid  forcible  wrection,  (3)  osteotomy  or 
osteectomy,  (4)  osteo-  or  artho-clasy,  and  (5)  subcutaneous 
or  open  divisio?i  of  adhesions.  But  before  undertaking  any 
operation  the  questions  to  decide  are  : 

1.  How  to  remedy  the  inconvenience  caused  by  immo- 
bility. 

2.  The  proper  method  to  adopt  in  any  given  case. 

3.  The  advantage  to  be  derived  by  any  operation. 

4.  The  nature  and  extent  of  the  operation  necessary  to 
correct  or  remedy  the  deformity.     And 

5.  The  indications  and  contra-indications  for  the  vari- 
ous methods. 

D   D 


402 


BODILY   DEFORMITIES. 


All  these  will  vary  according  to  the  nature  of  the  anchy- 
losis. If  it  be  fibrous  and  soft,  instrumental  or  manual 
means  will  suffice ;  but  if  it  be  fibrous  and  firm,  it  may  be 
necessary  to  resort  to  gradual  or  rapid  mechanical  reduc- 
tion, or  even  to  osteotomy  or  osteectomy.  In  bony  anchy- 
losis, osteoclasy,  arthroclasy,  osteotomy,  and  excision  have 
all  to  be  duly  estimated.  Mechanical  extension  may,  with- 
out any  operative  procedures,  be  of  undoubted  service  in 
suitable  cases,  and  may  be  executed  by  splints  with  cog- 
wheel joints  producing  gradual  extension,  or  by  one  of  the 


Figs.  198  and  199. — Instruments  for  the  gradual  correction  of  elbow  and  wrist 

anchylosis. 


modes  illustrated  by  the  accompanying  figures,  which  suffi- 
ciently explain  themselves,  more  rapid  reduction  of  the 
deformity  may  be  accomplished. 

Forcible  Correction  of  Anchylosis. — Briseme?it force, 
or  Redressement  brusque.  This  may  be  repeated  or  entire  ; 
the  former  consists  in  partial  rupture  of  adhesions  at 
different  sittings,  and  the  latter ;  in  correction  at  one  opera- 
tion. It  may  be  attempted  in  cases  of  fibrous  anchylosis 
if  all  active  inflammation  have  ceased ;  but  in  scrofulous 
cases,  not  for  some  considerable  time  after  inflammatory 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.         403 

mischief  has  subsided,  and  the  general  health  of  the  patient 
must  of  course  be  good.     In  such  cases  it  is  well  tp  recol- 
lect that  in  young  subjects  an  epiphysis  may  be  separated, 
or  the  adhesions  may  be  so  strong  that  a  fracture  may 
result ;  but  as  the  former  has  occurred  to  me  in  two  or 
three  cases,  with  good  correction  of  position  and  a  service- 
able limb,  and  as  I  have  had  the  opportunity  of  watching 
the  cases  for  some  years,  and  observing  that  no  noticeable 
defect  in  the  growth  of  the  limb   occurred,  I  do  not  think 
that  this  accident,  if  occurring  in  adolescence,  is  of  the 
serious  import  some  would  impart  to  it ;  though  it  must  be 
stated  that  Bauer*  had  to  amputate  in  a  lad  of  sixteen  for 
such  an  occurrence,  and  that  in  delicate  or  growing  chil- 
dren, epiphysial  separation  may  lead  to  inflammatory  mis- 
chief.    Preliminary  to  manual  or  instrumental  reduction 
tenotomy    may    be    necessary,   and    my    colleague,    Mr. 
Brodhurst,  adopts  this  plan    almost  invariably.      I  have 
already  pointed  out  that  in  certain  pathological  conditions 
of  the  knee  it  is  useless,  but  there  are  other  cases  in  which 
such  a  proceeding  is  undoubtedly  serviceable.     Brodhurst 
statest  that  cicatrices,  tense  fasciae,  and  contracted  tendons 
'  should  be  divided  and  the  punctures  allowed  to  heal  before 
forcible  means  are  adopted,  then  moderate  force,  generally 
manual,    is    to    be    used,    after   the    muscles    have  been 
thoroughly  paralyzed  by  an  anaesthetic.      The  adhesions 
should  be  ruptured  first  in  the  direction  of  flexion  and 
then  in  extension  ;  but  Bauer  considers  extension  safer  than 
flexion.     I  would  advise  that  in  children  and  adolescents, 
the  hands  of  the  surgeon  should  be  close  to  the  joint 
grasping  the  bones  near  their  epiphyses.     This  plan  will 
prevent,  in  the  majority  of  cases,  separation  of  epiphyses, 
whereas,  if  the  further  end  of  the  limb  were  grasped  the 

*'  "  Orthopedic  Surgery,"  New  York,  1868. 
t  "Anchylosis  and  its  Treatment,"  Second  Edition. 

D  D   2 


404  BODILY    DEFORMITIES. 

long  leverage,  giving  greater  power,  might  lead  to  epiphysial 
separation.     After  the  adhesions  have  been  broken  down, 
Brodhurst  recommends  that  no  attempt  should  be  made  to 
directly  correct  the  position  of  the  limb,  but  that  it  should 
be  fixed,  in  its  original  deformed  position,  in  some  splint 
or  apparatus,  and  that  the  joint  should  remain  at  rest  till 
all  tenderness  has  ceased,  when  passive  movements  daily, 
or  every  second  or  third  day,  should  be  resorted  to,  or  at 
longer  intervals  if  necessary,  and  if  these  cause  pain,  hot 
fomentations  or  local  hot-air  baths  may  be  necessary,  and,  if 
any  tendons  have  been  divided,  subsequent  extension  must 
be  very  gradual  to  prevent  their  being  over-stretched.     In 
rheumatic   cases,    muscular   rigidity   is    more    difficult  to 
conquer,  he  says,  than  the  anchylosis  itself.     The  difficulty, 
in  my  opinion,  in  such  cases  is  not  to  correct  the  defor- 
mity, neither  is  there  any  great  risk  in  doing  so,  as  I  have, 
repeatedly  operated  in  such  cases  with  impunity ;  but  the 
great  difficulty  consists  in  getting  a  movable,   firm,  and 
useful  articulation,  as  there  is  always  a  great  tendency  to 
refixation.     In  hospital  practice,  I  have  applied  an  ice-bag 
after  breaking  down  the  adhesions,  which  have  often  given 
way  with  a  loud  snap,  and   as    soon  as  tenderness  was 
diminishing,    anaesthetics   have    been     administered    and 
passive  motion  resorted  to,  but  after  leaving  a  hospital 
some  of  these  cases  have  been  seen,  and  it  has  been  found 
that  the  patient  has  not  continued  either  active  or  passive 
motion  and  the  joint  has  become  fixed,  though  in  a  far 
better  position.     A  few  brief  directions  for  the  conduct  of 
this  method  in  the  principal  joints  will  be  of  service  : — 

Shoulder. — The  palm  of  one  hand  should  be  placed 
over  the  affected  shoulder,  grasping  the  humeral  head  in 
front  and  behind,  the  other  should  grasp  the  elbow  in  a 
flexed  position,  and  the  humerus  should  be  rotated  out  and 
in,  then  it  should  be  moved  antero-posteriorly,  and  subse- 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.         4°5 

quently  adducted  and  abducted,  afterwards  circumducted, 
at  first  with  the  limb  near  the  thorax,  and  subsequently 
gradually  raising  it.  Great  care  must  be  taken  not  to 
attempt  abduction  before  the  adhesions  have  been  freely 
separated,  lest  downward  or  forward  dislocation  be  pro- 
duced, or  mischievous  laceration  of  the  soft  parts  on  the 
inner  side  of  the  joint  result. 

Elbow.— One  hand  should  grasp  the  fore-arm  firmly 
above  the  wrist,  and  the  palm  of  the  other  should  rest  on 
the  olecranon  with  the  fingers  encircling  the  joint,  and  the 
thumb  resting  on  the  head  of  the  radius.  First  flexion 
and  then  extension,  the  former  in  short,  sharp  jerks,  should 
be  employed.  Then  movements  of  pronation  and  supina- 
tion should  be  adopted,  followed,  if  necessary,  by  division 
of  the  biceps  tendon— which  must  be  done  from  the  inner 
side,  away  from  the  brachial  artery-and  only  if  extension 
cause  it  to  stand  well  out,  away  from  the  blood  vessels. 
Care  must  be  taken  not  to  commence  by  extension,  lest 
the  radius  be  displaced  forwards. 

Wrist  and  Fingers.— Each  finger  should  be  grasped 
between  the  fingers  of  one  hand,  while  the  thumb  and  two 
first  fingers  of  the  other,  flex  and  extend,  first  the  ungual, 
then  the  middle,  and  subsequently  the  proximal  phalanges. 
Flexion  is  the  first  movement,  and  should  be  done  quickly, 
and  after  each  finger  has  thus  been  treated  they  should  all 
be  grasped  and  served  similiarly.     The  metacarpophalan- 
geal joint  should  be  flexed;  extended,  and  circumducted. 
In  wrist  disease  the  fingers  are  often  fixed  by  teno-synovitis, 
and  must  first  be  dealt  with.     To  free  the  wrist,  the  lower 
end  of  the  fore-arm  should  be  grasped  in  one  hand,  and  the 
•■  carpus  and  metacarpus  in  the  other.     Flexion  is  the  first 
movement,   then  extension  followed  by  rotation.     Rapid, 
short  jerks  are  most  effectual  in  breaking  down  adhesions 
of  these  parts,  and  passive  motion  must  subsequently  be 


406  BODILY   DEFORMITIES. 

daily  adopted  to  prevent  refixation  of  the  joint.  Luxation 
of  the  carpal  bones  is,  even  in  these  cases,  a  rare  occur- 
rence. 

Ankle. — In  cases  of  rectangular  anchylosis,  if  it  be 
desired  to  make  attempts  to  restore  motion,  much  force 
should  not  be  used  in  breaking  down  adhesions,  for  the 
mobility  of  the  tarsal  joints  largely  compensates  fixity  of 
the  ankle.  This  latter  may  be  ascertained  by  pressing  the 
thumb  or  finger  firmly  between  the  tibialis  anticus  and  tip 
of  the  internal  malleolus,  and  by  flexing  and  extending 
the  foot  with  the  other  hand.  If  the  astragaloid  head  and 
neck  do  not  move,  then  it  may  be  concluded  that  the 
ankle  joint  is  fixed.  If  the  foot  be  anchylosed  in  extension, 
the  heel  should  be  grasped  with  one  hand  and  the  ante- 
rior part  of  the  foot  with  the  other,  and  sudden  jerks  in  the 
direction  of  dorsal  flexion  should  first  be  adopted.  If  the 
tendon-Achillis  resist  it  should  be  divided.  In  some  cases 
it  may  be  necessary  to  adapt  a  casing  to  the  foot,  to  which 
a  handle  affording  leverage  is  attached,  and  even  great 
force  may  fail,  as  the  astragalo-scaphoid  and  calcaneocuboid 
joints  are  very  movable,  and  thus  diminish  much  of  the 
force  intended  for  the  ankle.  If  there  have  been  much, 
peri-articular  inflammation,  graduated  extension  must  be 
adopted,  for  fear  of  tearing  the  tibial  vessels,  and  force 
should  be  carefully  regulated  for  fear  of  spraining  some  of 
the  tarsal  articulations.  If  these  attempts  at  reduction  have 
failed,  the  question  of  partial  excision,  or  of  breaking  down 
the  adhesions,  after  opening  the  joint,  will  have  to  bejcon- 
sidered.  *  I  prefer  the  latter  proceeding,  because  the  joint 
can  readily  be  reached  by  a  single  longitudinal  anterior  in- 
cision without  damage  to  vessels,  nerves,  or  tendons,  and 
fibrous  bands  may  be  loosened,  and  the  foot  fixed  at  a  right 
angle. 

Knee. — The  process  will  vary  according  to  whether  the 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.        407 

knee  be  fixed  in  a  straight  or  bent  position,  the  latter  being 
much  commoner.  In  these  cases  the  deformity  may  be 
reduced  by  allowing  the  leg  to  project  beyond  the  operating 
table  or  bed,  and  by  fixing  or  setting  the  thigh  against  the 
latter ;  then,  grasping  the  leg  near  the  ankle,  using  it  as  a 
lever,  and  applying  short,  sharp  jerks  until  a  cracking  sound 
be  heard.  If  the  gradual  or  repeated  method  be  adopted, 
proceedings  must  now  cease ;  but  I  commonly  proceed  to 
complete  flexion,  and  then  to  as  much  extension  as  can  be 
gained,  adopting  short,  sharp  manipulations.  Care  should  be 
taken  to  place  the  fingers  on  the  tibial  tuberosities,  so  as  to 
note  that  they  follow  normally  when  extension  is  attempted, 
and  that  neither  lateral  motion,  nor  rotation  of  the  leg  or 
thigh,  is  produced.  Another  plan  that  I  have  found  service- 
able is  for  the  surgeon  to  grasp  and  steady  the  lower  part  of 
the  thigh  between  his  thorax  and  arm,  while  the  fore-arm  and 
hand  encircles  the  knee,  his  free  hand  grasping  the  leg,  and 
proceeding  as  before.  Tense  tendinous  and  fascial  struc- 
tures have  to  be  divided,  and  this  should  be  done  from  the 
outer  and  inner  side,  instead  of  from  the  popliteal  space, 
as  these  punctures  may  become  rents  in  attempts  at  exten- 
sion. It  is  less  difficult  to  act  upon  a  knee  fixed  in  exten- 
sion. The  back  of  the  patient's  thigh  may  rest  upon  the 
surgeon's  knee  while  he  grasps  the  lower  part  of  the  leg, 
adopting  successive  sharp  jerks  ;  or  the  leg  may  be  steadied 
or  fixed  tothe  bed  or  operating  table,  and  pressure  may  be 
applied  by  the  hands  to  the  leg  from  before  backwards. 

In  attempts  at  correcting  the  deformity,  if  the  adhesions 
be  firmest  at  the  back  of  the  joint,  the  anterior  part  of  the 
tibial  head  will  often  be  impacted  by  cancellous  fracture  of 
the  femoral  condyles,  and  if  the  union  be  strongest  in  front 
of  the  joint,  luxation  backwards  is  the  usual  result ;  but  I 
have  found  that  tenotomy  of  the  hamstrings,  either  before 
or  after  the  forcible  rupture  of  adhesions,  combined  with 


4o8 


BODILY    DEFORMITIES. 


extension,  will  considerably  assist  in  bringing  the  limb  into 
a  good  position. 

In  cases  where  the  patella  is  fixed  to  the  femoral  condyles 
attempts  at  reduction  may  end  in  dislocation  back,  or  back' 
and  out,  or  to  rupture  of  the  fattily  degenerated  quadriceps 
above  the  patella.  This  latter  is  indicated  by  a  hollowness 
above  the  patella  as  the  leg  is  being  straightened,  and 
further  attempts  should  be  desisted  from.  A  back  splint 
with  foot-piece  should  then  be  applied,  with  a  firm  pad  at 
the  calf,  and  pressure  should  be  applied  to  the  thigh  directly 


Fig.  200. — Diagram  of  infraction  of 
tibia  into  cancellous  tissue  of  femoral 
condyles  in  attempted  reduction,  when 
the  anchylosis  is  strongest  posteriorly. 


Fig.  201. — Diagram  of  sub- 
luxation in  attempted  reduc- 
tion when  the  anchylosis  is 
strongest  anteriorly. 


backwards  at  the  lower-third  of  the  femur.  If  necessary, 
in  ten  days  to  a  fortnight  further  attempts  may  be  made, 
and  may  prove  successful.  If  firm  fibrous  adhesions  con- 
nect the  patella  to  the  condyle  these  may  be  subcutaneously 
severed  by  the  use  of  a  strong  tenotome.  One  puncture, 
should  be  at  the  inner  and  lower  edge  of  the  patella,  and 
the  other  at  the  upper  and  outer,  and  the  instrument  should 
freely  separate  adhesions  in  all  directions,  the  leg  should 
then  be  well  worked  and  the  patella  subsequently  grasped, 
and  freely  moved  about.  Some  surgeons,  however,  prefer  to 
separate  patellar  adhesions  before  acting  on  the  leg.     An 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.        4°9 

ice-bag  should  be  subsequently  applied  to  the  limb  over  a 
firm  flannel  bandage.  This  operation  is  recommended  by 
Celsus,*  and  has  been  reintroduced  by  Mr.  Maunder  in  two 
cases  at  the  London  Hospital,  t  I  have  once  adopted  it, 
but  prefer  brisement,  either  gradual  or  entire. 

Hip.— The  patient  being  in  the  supine  position,  the  pelvis 


Figs.  202  and  203.— Bony  anchylosis  of  hip  and  contraction  of  knee  in  a  young 
man  of  twenty-three,  before  and  after  operation.  Cervical  osteotomy  at  hip  and 
tenotomy  of  hamstrings.     The  knee  was  first  corrected  and  then  the  hip. 

should  be  firmly  steadied  with  a  broad  strong  leather  strap 
fixed  to  the  operating  table.  The  tuber  ischii  should  be 
close  to  the  table's  edge.  The  surgeon,  grasping  the  thigh 
just  above  the  knee,  should  apply  successive  sharp  jerks 

*  Book  7,  c.  4,  sec.  2. 

t  British  Medical  Journal,  1875,  Vol.  2,  p.  586,  etc. 


410  BODILY   DEFORMITIES. 

in  the  direction  of  flexion,  aiding  this  movement  with 
his  body-weight,  by  pressing  with  his  thorax  on  the  bent 
knee.  When  flexion  has  been  sufficiently  accomplished, 
extension  must  be  adopted  with  quick,  short  jerks.  This 
should  be  followed  by  abduction,  and  if  the  abductors 
resist  they  must  be  divided.  Circumduction  should  next 
be  adopted,  and,  if  necessary,  the  patient  placed  on  a 
mattress  on  the  floor.  These  proceedings  must  be  adopted 
with  caution,  judgment,  and  experience,  because  fracture  of 
the  femoral  neck  may  result,  as  in  a  case  recorded  by 
Tillaux.  But  this  accident  is  not  of  itself  to  be  feared,  as 
good  position  and  a  useful  limb  have  resulted,  so  that 
some  surgeons  look  upon  it  as  desirable,  if  it  can  be  effected 
without  injury  to  important  neighbouring  parts. 

Tenotomy. — Tense  tendons  and  fascia  on  the  outer  and 
inner  side  of  the  joint  may  need  division,  the  adductors 
and  gracilis  may  be  divided  by  a  puncture  passing  between 
them  and  the  femoral  vessels,  and  the  cutting  edge  of 
the  knife  being  turned  towards  the  skin,  a  sawing  motion 
of  the  tenotome,  with  pressure  of  two  fingers  of  the 
opposite  hand  on  either  side  of  the  blade,  will  effect  the 
division.  The  tensor  fascia  femoris  and  fascia  lata  may  be 
divided  through  one  puncture  a  little  below,  and  internal 
to  the  anterior  superior  iliac  spine ;  the  cutting  edge  is 
then  turned  outwards,  and  a  sawing  movement  adopted 
until  these  structures  are  felt  to  be  freely  divided.  The 
rectus  femoris  may  be  divided  by  a  puncture  at  its  outer 
edge,  about  half  an  inch  below  the  anterior  inferior  spine 
of  the  ilium;  the  blade  must  pass  deeply  and  go  well 
behind  the  origin  of  the  tendon.  The  cutting  edge  must 
then  be  turned  towards  the  skin,  the  handle  depressed,  and 
a  sawing  motion  will  complete  the  division. 

In  bony  anchylosis,  and  in  the  firmest  kinds  of  fibrous 
union,  either   arthodasy,  osteodasy,  osteotomy,   or  excision 

A 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.         411 

may  have  to  be  selected,  and  some  of  these  proceedings 
vary  according  to  the  joint  affected.  In  the  shoulder, 
excision  of  the  head  of  the  humerus  appears  to  be 
the  best  operation,  as  it  usually  gives  good  subse- 
quent mobility,  but  if  mere  rectification  of  position  with- 
out motion  be  desired,  linear  osteotomy  will  suffice.  In 
the  elbow,  excision  is  the  best  plan,  and  partial  excision 


Figs.  204  and  205. — Cross  or  X  -shaped  anchylosis  in  a  girl  of  fifteen  after  morbus 
coxae  of  right  side,  which  was  osteotomized,  and  on  the  left  side  the  fibrous  anchylosis 
was  broken  down. 

is  preferred  by  Watson,  and  Annandale  of  Edinburgh.  I 
have  removed  the  articular  surface  of  the  humerus  in  three 
such  cases  with  very  satisfactory  results.  In  osseous  anchy- 
losis of  the  wrist,  excision,  either  partial  or  complete,  may 
be  performed,  but  if  the  fingers  be  fairly  movable  no  opera- 
tive treatment  is  necessary. 


412 


BODILY   DEFORMITIES. 


In  the  ankle,  bony  anchylosis  at  a  right  angle  is  best  left 
to  itself,  but  partial  or  complete  excision  may  be  adopted 
in  other  vicious  positions  of  the  joint.  Many  plans  have 
been  devised  and  adopted  in  osseous  anchylosis  of  the 
hip  and  knee,  and  I  will  now  consider  them  : — 

At  the  hip)  the  earlier  operations  were  by  large  open 
wound,  but  Brodhurst  and  Adams  operated  some  years  ago 
by  much  smaller  incisions.  The  section  of  bone  was  formerly 
effected  by  means  of  a  small  saw  introduced  through  an 
opening  sufficiently  large  to  admit  it.     In  the  accompany- 


Fig.  206. — Diagrams  of  osteotomy- 
lines  for  hip  anchylosis  :  1,  Rhea  Bar- 
ton's ;  2,  W.  Adams's  ;  3,  My  incom- 
plete infra-trochanteric  ;  4,  Gant's ;  6, 
Volkmann's ;  7,  Sayre's. 


Fig.  207.  —  1,  Osteotomy 
line,  in  fusion  of  both  bones ; 
2,  The  plan  which  I  have 
oftenest  adopted. 


ing  diagram,  No.  2  shows  the  line  of  Adams's  operation ; 
but  it  must  be  borne  in  mind  that  in  old  cases  the  greater 
part  of  the  neck  of  the  femur  has  become  welded  to 
the  innominate  bone,  so  that  Fig.  207  more  accurately 
represents  the  condition  of  parts  and  the  line  which  the 
chisel  should  take.*  The  steps  of  osteotomy  are  so  well 
known  now-a-days,  and  are  sufficiently  described  in  the 
chapter  on  Genu  Valgum,  that  I  need. not  now  occupy 

*  Mr.  Keetley  has  published  an  excellent  paper  on  Osteotomy  in 

the  British  Medical  fournal  for  this  year. 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS.         413 


space  by  going  into  the  details.  Here,  as  in  knock-knee 
or  bowed  legs,  the  osteotomy  may  be  complete  or  partial, 
its  object  being  to  correct  deformity  and  to  lengthen  the 
limb,  and  not,  as  Sayre  attempted,  to  establish  a  false  joint, 
which,  though  not  impossible,  leads  to  a  weak  limb.  Line  7 
Fig.  206  shows  the  situation  of  Sayre's  operation  for  a  new 
joint,  and  the  shade  indicates  the  hollowing  out  of  the 
upper  end  of  the  bone  and  the  portion  of  bone  removed. 
Line  1  shows  Rhea  Barton's  oparation.  and  this  was  the 


Figs.  20S,  209  and  210.— Bony  anchylosis  of  right  hip  and  contracted  knees  in  a 
girl  aged  eleven.  Posterior  and'  anterior  views  before  operation.  The  figure  on  the 
right  shews  the  deformity  corrected. 

first  recorded  for  bony  anchylosis  of  the  hip.  Line  4 
shows  Gant's  infra-trochanteric  operation,  and  line  3  shows 
the  incomplete  osteotomy  usually  adopted  by  me.  All  I 
need  further  say  is  that  I  do  not  operate  under  the  spray, 
and  that  I  close  the  wound  with  a  pad  of  oiled  lint,  over 
which  is  put  a  flannel  roller  or  cotton-wool,  and  I  use 
either  a  plaister  of  Paris  spica  bandage,  keeping  the  leg 
extended  by  weight  and  pulley,  or  attach  the  limb  to  a 
long  splint  with  extension  arrangements.     Volkmann  has 


414  BODILY    DEFORMITIES. 

advised  two  plans  for  the  formation  of  an  artificial  joint. 
The  first  operation  consists  in  making  a  new  joint  between 
the  trochanters,  and  the  second  attempts  this  just  below  the 
femoral  head.  The  bone  is  divided  along  Rhea  Barton's 
line  ;  the  lower  fragment  is  then  rounded  off,  and  the  upper 
excavated.  The  second  operation  resembles  the  first,  but 
its  position  is  higher  up. 

In  angular  osseous  anchylosis  of  the  knee  the  operation 
formerly  adopted  was  excision  of  more  or  less  of  the  anchy- 
losed  parts.  Number  i  in  Fig.  213  shows  Rhea  Barton's 
wedge-shaped   excision   of  the  femur.      Number  2  shows 


Figs.  211  and  212. — Diagrams  of  Volkmann's  operations  for  the  formation  of  a  new 

joint  near  the  hip. 

Gordon  Buck's ;  3  is  Eantrikin's ;  4  Langenbeck's.  Gross, 
of  Philadelphia,  and  Mr.  Stromeyer  Little,  formerly  of  the 
London  Hospital,  have  also  successfully  performed  subcuta- 
neous osteotomy,  separating  the  femur  from  the  tibia. 
Barwell  divides  the  operation  into  two  stages,  dividing  the 
femur  above  the  joint  in  one  stage,  and  the  tibia  and  fibula 
below  it  at  a  later.  If  there  be  femoro-patellar  bony 
anchylosis  and  fibrous  anchylosis  in  the  remaining  part  of 
the  articulation,  the  latter  may  be  separated  subcuta- 
neously,  as  before  described,  or  by  means  of  a  small 
chisel,  before  the  remaining  adhesions  are  attempted  to  be 


ANCHYLOSIS    AND    UNREDUCED    DISLOCATIONS. 


415 


broken  up.  In  these  cases,  after  flexure  of  the  limb,  the 
joint  should  be  well  surrounded  with  cotton-wool,  and 
evenly  and  pretty  firmly  bandaged,  and  a  rubber  bandage, 
judiciously  applied,  is  of  great  advantage  in  preventing 
inflammatory  effusion.  An  ice-bag  may  be  applied  for  two 
or  three  days  if  necessary.  Patellar  and  other  strong 
fibrous  intra-articular  adhesions  have  also  been  separated 
by  open  wound.  There  is  a  good  deal  of  bleeding  in  these 
cases,  and  in  the  few  cases  which 
I  have  seen  operated  on  by  this 
plan,  anchylosis  returned  after  a 
prolonged  convalescence. 

In  many  cases  of  anchylosis, 
as  well  as  in  the  numerous  oste- 
otomies I  have  had  occasion  to 
perform  chiefly  in  the  lower 
limbs,  I  have  had  the  good 
fortune  never  to  lose  life,  joint, 
nor  limb,  but  always  to  con- 
siderably improve  position,  giv- 
ing often  lengthened,  and  always 
serviceable,  limbs. 

Osteoclasy  and  arthrodasy,  as 
described  in  the  section  on  genu 
valgum,  may  also  be  applied  in 

cases  of  anchylosis,  and  especially  at  the  knee.  French 
surgeons  are  accumulating  a  good  experience  with  these 
methods,  but  so  far  the  proceedings  have  not  been  at  all, 
or  scarcely  at  all,  adopted  in  this  country.  It  seems  to  me, 
in  proper  cases,  a  very  suitable  operation. 

Anchylosis  of  the  Jaw. — This  is  almost  always  false, 
and  its  causes,  are  in  general,  those  which  produce 
anchylosis  in  other  joints,  but  certain  regional  affections 
are  prone  to  fix  the  temporo-maxillary  articulation,  such  as 


Fig.  213.— Diagram  of  opera- 
tions for  angular  anchylosis  of 
knee.  1,  Rhea  Barton's  cuneiform 
osteectomy;  2,  Gordon  Buck's, 
including  patella,  and  Eantrikin's 
horizontal  cut  passes  to  3.  4 — 3, 
Line  of  incision  for  subcutaneous 
osteotomy  of  Langenbeck  and 
Gross. 


416 


BODILY   DEFORMITIES. 


inflammatory  affections  of  the  teeth  and  alveoli,  suppuration 
of  the  middle  ear,  severe  stomatitis,  salivation  from  mercury, 
inflammation  about  the  parotid  glands,  &c.  Mr.  Hilton* 
relates  a  case  of  true  or  osseous  anchylosis  accompanying 
disease  of  the  cervical  vertebrae ;  and  cicatrices  of  burns  of 
the  mucous  membrane,  or  those  due  to  stomatitis,  cancrum 


Figs.  214  and  215 — Bony  anchylosis  of  hip  in  a  man  aged  fifty-four,  before  and -after 

operation. 


oris,  &c,  also  lead  to  false  anchylosis  through  abolishing  the 
normal  elasticity  of  the  mucous  membrane  of  the  cheek, 
which  is  converted  into  a  fibrous  material.  Muscular  con- 
traction, which  is  generally  secondary  to  inflammatory 
mischief  of  the  teeth,  jaws,  or  neighbouring  soft  parts,  may 
also  cause  closure  of  the  jaws. 

*  "  Lectures  on  Rest  and  Pain,"  Third  Edition,  1880. 


ANCHYLOSIS   AND    UNREDUCED    DISLOCATIONS.         417 

Treatment. — This  varies  according  to  whether  the 
anchylosis  be  fibrous  or  bony.  In  the  former,  gradual 
dilatation  by  wedges  acted  on  by  screws  placed  between  the 
molars  on  the  affected  side,  will  often  afford  permanent 
relief,  but  the  procedure  may  be  rapidly  done  under  anaes- 
thesia, and  when  the  adhesions  are  well  broken  down  sub- 
sequent passive  and  voluntary  motion  should  be  resorted 
to.  In  this  proceeding  care  should  be  taken  not  to  pro- 
duce dislocation.  Subsequent  inflammation  of  the  joint  is 
rare.  When  the  anchylosis  is  due  to  contracted  cicatrices, 
these  may  be  carefully  divided,  either  partially  in  several 
places,  or  completely,  in  one  or  more,  and  stretched,  and 
the  jaw  should  be  kept  open  during  the  process  of  healing  ; 
and  it  must  further  be  borne  in  mind  that  the  new  cicatricial 
tissue  is  very  apt  to  contract  and  reproduce  the  deformity, 
so  that,  where  possible,  grafts  should  be  implanted,  as  the  tis- 
sue resulting  therefrom  is  less  contractile.  Operations  upon 
cicatrices  within  the  mouth  can  only  be  performed  if  the 
cheek  structures  are  not  affected  by  the  cicatricial  contrac- 
tion. If  these  means  fail,  or  be  thought  inadvisable,  the 
lower  jaw  may  be  divided  at  some  suitable  spot,  and  a 
false  joint  formed.  Esmarch's  plan  consists  in  removing 
a  small  piece  of  bone  in  front  of  the  cicatrix,  and  forming 
a  false  joint.  Rizzoli  simply  divides  the  jaw.  In  the 
latter  case,  unless  constant  motion  between  the  parts  be 
kept  up,  reunion  is  apt  to  occur.  The  former  operation  is 
best  suited  to  cases  of  unilateral  anchylosis.  Muscular 
anchylosis  is  oftenest  due  to  contraction  of  the  masseter, 
in  which  case  it  may  have  to  be  divided. 

Bony  anchylosis  is  fortunately  rare.  In  such  cases  the 
ascending  ramus  will  have  to  be  divided  high  up,  close  to 
the  joint ;  or  the  condyle,  or  its  remains,  will  have  to  be 
excised,  a  proceeding  of  some  difficulty,  requiring  correct 
anatomical  knowledge  and  operative  skill. 

E   E 


418  BODILY   DEFORMITIES. 

Anchylosis  of  the  Joints  of  the  Hand  and  Foot. — 

In  the  hand,  unless  the  position  be  such  as  to  interfere  with 
the  occupation  of  the  patient,  the  parts  are  better  left  alone, 
except  in  cases  of  fibrous  anchylosis,  which  are  generally 
readily  amenable  to  treatment.  In  bony  anchylosis  excision 
has,  in  some  cases,  proved  useful  in  my  hands,  but  for 
working  people  amputation  is  the  best  resource,  as  time 
with  them  is  of  great  moment,  and  one  cannot  certainly 
promise  a  strong  and  useful  limb  after  excision.  In  the 
foot,  if  the  tarsal  joints  be  anchylosed  and  any  great  incon- 
venience be  complained  of,  the  foot  should  be  examined 
under  anaesthesia,  and  fibrous  adhesions  may  be  broken  down 
and  kept  separated  by  subsequent  passive  motions  ;  but  if 
these  methods  fail,  partial  or  complete  excision  may  have  to 
be  adopted,  especially  if  great  pain  and  inconvenience  be 
complained  of.  In  fibrous  anchylosis  of  the  phalangeal 
joints  brisement  force  may  be  of  service,  but  if  the  adhesions 
be  very  firm  or  bony,  amputation  must  be  performed.  I 
have  excised  the  metatarsophalangeal  joint  of  the  great 
toe  three  times,  once  for  disease  of  the  joint  subsequent 
to  inflamed  bunion,  once  for  anchylosis,  and  once  for 
rheumatic  arthritis  with  pain  and  lameness,  and  a  service- 
able foot  resulted  in  each  case. 

Unreduced  Dislocations. 

Such  cases  are  not  infrequently  seen  by  orthopaedic  sur- 
geons, therefore  a  brief  account  of  the  proper  method  of 
dealing  with  them  will  be  appropriate.  Those  desiring  to 
enter  further  into  the  pathology  of  this  subject  must  consult 
special  works  on  dislocations. 

Treatment. — This  will  depend  upon  the  age  of  the 
patient,  the  history,  nature,  and  subsequent  complications 
of  the  case,  and  on  the  extent  of  the  changes  which  have 


UNREDUCED    DISLOCATIONS.  419 

arisen  subsequent  to  its  occurrence.  Old  dislocations  have 
been  reduced  many  years  after  the  accident,  and,  on  the 
other  hand,  some  recent  ones  have  been  unable  to  be 
reduced,  and  this  in  the  ball-and-socket  joints  has  been  due 
to  reunion  of  the  rent  in  the  capsule.  The  condition  of 
the  parts  can  only  be  satisfactorily  made  out  under  anaes- 
thesia, when  careful  attempts  should  be  made  to  break  down 
all  adhesions.  If  the  misplaced  bone  is  found  to  move 
sufficiently  freely,  methodical  attempts  at  reduction,  accord- 
ing to  the  directions  to  be  found  in  general  works  on  sur- 
gery, must  be  made,  and  when  this  is  effected  the  limb 
should  be  kept  quiet  for  a  few  days  with  an  ice-bag  applied 
over  the  joint.  Passive  motion  with  gentle  frictions  and 
massage  should  then  be  commenced  and  gradually  in- 
creased, care  being  taken  not  to  give  much  pain. 

Where  muscles,  tendons,  or  fascial  bands  are  tense  and 
offer  opposition  to  reduction  they  must  be  tenotomized, 
and  this  should  be  done  about  three  days  before  attempts 
at  reduction  are  adopted,  so  as  to  allow  the  punctures  to 
heal.  The  hip  if  reduced  will  be  much  more  useful  than 
the  shoulder,  which,  though  much  more  easily  reducible, 
does  not,  as  a  rule,  return  to  its  normal  functions  nearly  so 
rapidly.  When  repeated  attempts  at  reduction  have  failed, 
the  propriety  of  excision  will  have  to  be  considered,  or  an 
attempt  may  be  made  to  divide  the  adhesions  by  open 
wound  or  subcutaneously.  It  may  be  advisable  in  some 
cases  to  try  and  form  a  new  joint  just  below  the  humoral 
head  in  old  shoulder  dislocations.  Mr.  W.  Adams  has 
recently  advocated  at  the  Medico-Chirurgical  Society,  exci- 
sion of  the  femoral  head  in  old  unreducible  dislocations  at 
the  hip,  following  Mr.  Rawdon. 

Complications. — Large  vessels  and  nerves  have  been 
torn  in  the  attempt  to  reduce  old  dislocations  of  the 
shoulder   and  knee.      This   is  partly   due  to   their  being 

E   E   2 


420  BODILY    DEFORMITIES. 

involved  in  the  inflammatory  mischief  resulting  from  the 
accident,  and  partly  to  their  contracted  state  j  but  it  may 
occur  in  old  people  through  atheroma  of  the  vessels. 
Several  instances  of  accident  have  been  recorded.  I  have 
seen  two  cases  which  were  admitted  into  the  London 
Hospital.  In  both  there  was  rupture  of  the  axillary 
vessels  prior  to  admission,  and  both  were  for  a  short 
time  under  my  care.  One  case  has  been  published  by 
my  colleague,  Mr.  Rivington.  A  French  surgeon  once  had 
the  misfortune  to  pull  off  the  arm  from  an  aged  person 
at  attempts  to  reduce  an  old  dislocation  of  the  shoulder ; 
and  Mr.  Thomas  Smith  has  recorded  a  somewhat  similar 
case  occurring  in  his  practice  at  Bartholomew's  Hospital,  in 
the  reports  of  that  institution  published  some  years  ago. 


421 


CHAPTER  XXV. 

NERVOUS  DEFORMITIES  AND  MUSCULAR  CONTRACTIONS. 

In  previous  sections  contractions  and  relaxations,  due  to 
muscular  or  nervous  irritation,  or  loss  of  power,  have  been 
described.  In  the  chapter  on  the  spine  mention  has  been 
made  of  paralytic  scoliosis,  and  I  need  here  only  advert  to 
those  deformities,  usually  temporary,  produced  by  nerve 
irritation  and  muscular  spasm,  such  as  opisthotonos  and 
pleurosthotonos ;  but  I  should  mention  that  there  are  some 
rare  cases  in  which  spinal  deformity  is  produced  by  tonic 
contraction,  and  subsequent  retraction,  of  the  spinal  muscles. 
In  these  cases— and  the  majority  of  the  few  I  have  seen 
have  been  in  children— the  deformity  results  subsequent  to 
tetanic  contractions  which  have  become  permanent  in 
certain  groups  of  muscles.  A  good  account  of  this  class  of 
case  will  be  found  in  the  recent  edition  of  Rilliet  and 
Bartez.* 

The  treatment  of  such  cases  consists  in  removing  any 
known  source  of  irritation,  the  use  of  massage,  electricity, 
and  gymnastics  to  the  affected  muscles,  and  the  judicious 
use  of  properly  constructed  apparatus. 

In  the  sections  devoted  to  the  upper  and  lower  limb,  the 
various  tonic  and  paralytic  deformities  have  been  described ; 
but  it  now  remains  to  give  a  succinct  account  of  certain 

*  "Traite  Clinique  et  Pratique  des  Maladies  de  l'Enfance,"  1884. 


422  BODILY    DEFORMITIES. 

paralytic  deformities  affecting  the  trunk  and  certain  groups 
of  muscles  of  the  limbs,  which  are  commonly  met  with  in 
orthopaedic  practice.  It  must  be  borne  in  mind  that  the 
surgeon,  generally,  sees  these  cases  when  the  muscles  are 
atrophied  and  a  paralytic  deformity  produced ;  but,  occa- 
sionally, he  gets  them  in  a  more  hopeful  stage,  and  is  able 
to  do  much  for  the  reconstruction  of  the  limb  functions. 
Paralytic  deformities  may  be  due  to  various  lesions  of  the 
nerve  centres,  which  will  be  found  described  in  modern 
text-books  on  nerve  diseases ;  but  I  may  say  that  the 
various  paralyses  of  the  limbs,  when  occurring  in  children, 
are  roughly  classed  by  the  surgeon  as  cases  of  infantile 
paralysis,  though  it  would  be  more  correct  to  call  them 
cases  of  paralysis  in  infants  and  children.  The  practical 
point  to  bear  in  mind  is,  that  no  operative  treatment  for 
correction  of  deformity  should  be  undertaken  in  the  inflam- 
matory or  irritative  stages  of  the  disease ;  but  there  is  little 
fear  of  this  in  ordinary  orthopaedic  practice,  for  cases  do 
not  usually  come  when  in  that  stage. 

Infantile  Spinal  Paralysis. 

Symptoms. — I  need  only  refer  to  those  symptoms 
which  are  observable  when  the  case  usually  presents  itself 
for  treatment  to  the  surgeon.  It  will  then  be  found  that  the 
paralysis  varies  in  extent  and  severity ;  it  may  affect  all  the 
limbs  or  only  one,  the  lower  being  the  most  frequently 
damaged,  and  even  these  it  may  affect  unequally,  the  leg 
muscles  being  commonly  affected,  while  sometimes  the 
muscles  of  the  thigh,  and  even  those  passing  from  the 
pelvis  to  the  femur,  may  be  involved.  There  may  be 
hemiplegia  or  cross -paralysis,  one  upper,  limb  and  the 
opposite  lower  limb  being  affected,  or  only  a  group,  or  even 
a  single  muscle,  may  be  affected.     The  temperature  of  the 


INFANTILE    SPINAL    PARALYSIS.  423 

affected  part  is  commonly  50  below  that  of  the  opposite 
side,  but  sensibility  is  not  usually  much  lessened,  though 
reflex  excitability  is  diminished  and  sometimes  abolished. 

To  test  the  state  of  the  muscles  galvanism  and  faradiza- 
tion must  be  employed ;  the  former,  even  in  low  tension, 
will  produce  movements,  before  the  atrophic  stage,  in  the 
most  paralyzed  muscles,  while  faradization  almost  always 
fails  to  produce  any  contraction  in  them.  This  reactive 
condition  is  present  in  the  first  stage,  which  varies  from  a 
month  to  six  weeks  before  the  second  or  atrophic  stage 
commences.  At  this  period  some,  or  even  the  whole  of  the 
paralysis  may  disappear;  but  when  this  is  not  the  case 
atrophy  rapidly  progresses,  and  the  skin  is  of  a  red  or 
purplish  hue,  the  circulation  of  the  limb  is  very  torpid,  as  is 
evidenced  by  pressure  of  the  finger,  when  a  white  patch 
appears  and  does  not  regain  its  colour  for  some  time.  I 
have  noticed  in  several  paralyzed  legs  that  a  broadish  collar 
of  subcutaneous  fat  is  present  about  two  or  three  inches 
above  the  malleoli.  In  this  condition  muscular  electric 
contractility  disappears,  so  that  the  strongest  induced 
currents,  and,  in  some  cases,  even  powerful  primary  currents, 
fail  to  induce  the  slightest  contraction  \  and  as  a  point  of 
diagnosis  it  should  be  mentioned  that  in  no  other  disease 
is  the  electric  excitability  so  thoroughly  abolished. 

This  muscular  atrophy,  accompanied  with  relaxation  of 
the  ligaments,  leads  to  altered  positions  of  the  bones  enter- 
ing into  the  joints,  so  that  in  old  cases  of  paralysis  of  the 
upper  limb  the  humerus  falls  away  for  an  inch  or  more 
from  the  glenoid  cavity,  and  the  passive  motion  of  the  joint 
is  much  increased,  and  the  latter  may  even  be  dislocated. 
The  elbow,  in  such  cases,  can  readily  be  hyperextended  so 
as  to  form  a  bulge  anteriorly,  and  the  fingers,  in  cases  of 
partly  recovered  paralysis  of  the  flexors,  can  be  put  by  the 
patient  in  a  state  of  extreme  extension,  so  as  to  have  a  dorsal 


424  BODILY    DEFORMITIES. 

concavity.  When  contraction  and  retraction  occur  we  may 
have  club-  or  griffin-hand,  the  fore-arm  being  firmly  flexed 
upon  the  arm,  and  the  latter  drawn  tightly  to  or  partly  across 
the  chest.  The  bones  become  atrophied  and  arrested  in 
growth,  and  therefore  the  limb  is  shorter  than  its  fellow, 
and  in  estimating  such  cases,  measurement  should  be  taken 
after  the  head  of  the  bone  is  brought  in  contact  with  the 
glenoid  cavity,  otherwise  its  weight  will  cause  the  separation 
already  referred  to,  and  will  lead  to  error.  Osseous  change 
is  not  always  present,  and  when  so,  indicates  extensive 
central  lesion. 

In  the  lower  limb,  the  muscles  commonly  aifected  are 
the  tibialis  anticus  and  extensors  of  the  toes,  the  peronei, 
the  quadriceps,  and  the  glutei.  In  the  upper  limb,  the 
deltoid  appears  to  be  most  commonly  attacked.  The 
method  of  progression  will  vary  according  to  whether  one 
or  both  limbs  be  affected.  If  only  one,  the  patient  will 
walk  with  a  crutch  under  the  arm  of  the  affected  side,  and 
if  the  diseased  limb  be  used  at  all  it  will  only  be  in  con- 
junction with  the  crutch,  which  acts  as  an  artificial  leg. 
The  patient,  standing  on  the  sound  limb,  projects  the  crutch 
with  the  dorsum  of  the  foot  touching  the  shaft  of  the 
instrument,  and  resting  the  leg  and  body  on  the  crutch, 
the  sound  limb  is  brought  forwards,  and  by  the  alternation 
of  these  motions  progression  is  secured.  When  both  limbs 
are  affected  the  trunk  is  slightly  inclined  forwards  and  the 
head  backwards.  There  is  great  lordosis,  the  pelvis  being 
carried  up  and  backwards.  The  thighs  are  semi-flexed  and 
adducted,  the  knees  semi-flexed  and  in  a  valgoid  con- 
dition. The  feet  are  extended  partly  by  their  weight,  and 
partly  by  the  contraction  of  the  tendo-Achillis,  and  scrape 
the  ground  during  walking.  In  standing,  equilibrium  is- 
maintained  by  widely  spreading  the  feet ;  but  in  walking 
with  crutches  these  patients-  generally  swing  one  or  both 


INFANTILE    SPINAL   PARALYSIS.  425 

limbs  forwards,  like  a  pendulum,  as  there  is  no  power  of 
extension.  If  only  one  limb  be  thrown  forward  the 
patient,  when  he  feels  it  to  have  firm  support,  throws  the 
other  limb  forwards  in  a  corresponding  manner ;  in  such 
cases  examination  will  show  that  the  glutei  are  wasted  and 
the  gluteal  fold  flattened.  The  thigh  muscles  may  be  a 
little  affected,  the  extensors  of  the  foot  are  considerably 
wasted,  the  flexors  are  somewhat  less  so.  Commonly, 
though  the  triceps  is  nearly  normal,  the  adductors  and 
sartorius  are  contracted  or  retracted.  In  such  cases  the 
pathological  condition  appears  to  be  a  disseminated 
sclerosis. 

In  other  cases  the  parents  tell  you  that  the  child  tumbles 
about,  that  it  can't  lift  its  feet  and  drags  them  upon  the 
ground,  and  a  slight  obstacle  upsets  it.  In  such  cases 
examination  shows  that  the  gluteal  and  femoral  muscles 
are  normal,  and  that  the  knees  are  not  at  all,  or  scarcely  at 
all,  in  a  valgoid  condition,  while  the  leg  muscles  are  much 
wasted.  The  calf  is  flat,  and  there  is  a  groove  where  the 
extensors  should  be  ;  the  ankle  joint  is  very  loose,  allowing 
of  considerable  motion  ;  and  the  walk  is  characteristic,  for 
the  child  throws  the  whole  limb  forwards  while  the  other  foot 
touches  the  ground.  If  the  child  be  examined  on  a  sofa 
with  the  legs  extended,  it  will  be  found  that  on  being  told 
to  raise  the  toes  it  can  do  so  but  very  slightly,  and  even 
this  will  be  prevented  by  gentle  pressure  with  the  finger 
on  one  of  the  toes.  If  the  foot  be  placed  in  semi-exten- 
sion and  the  child  told  to  flex  it,  it  will  easily  accomplish 
this  at  starting,  but  at  a  certain  point  it  stops  and  can't 
bring  the  foot  to  a  right  angle,  and  this  condition  if  allowed 
to  continue  will  result  in  paralytic  equinus,  because  of  the 
weight  of  the  foot  and  the  greater  power  of  its  extensors. 
The  skin  in  such  cases  is  subject  to  ulcerations,  and 
especially  to  pressure  sores.     There    is   another  class  of 


426 


BODILY    DEFORMITIES. 


cases  in  which  patients  apply  for  treatment  after  injuries 

about  the  knee  or  to  the  patella, 
and  it  will  be  found  that  the 
quadriceps  is  considerably  wasted, 
but  this  atrophy  is  the  result 
of  prolonged  rest  of  the  muscle 
occasioned  through  the  injury,  and 
also  through  the  continued  approxi- 
mation of  its  points  of  attach- 
ment. 

Treatment. — When  the  muscles 
are  contracted  or  retracted  tenotomy 
is  called  for,  care  being  taken  not 
to  attempt  to  correct  the  deformity 
too  rapidly,  and  also  to  avoid  pres- 
sure and  sores.  But  in  these  cases, 
after  the  deformity  is  corrected  and 
an  appropriate  instrument  applied, 
frictions,  massage,  electricity  and 
instructing     the     patient,     if     old 

enough,  to  exercise  frequent  voluntary  motion,  must  for  a 

long  time  be  resorted  to. 


Fig.  216. — Instrument  for 
paralysis  of  lower  limb,  with 
elastic  action  for  equinus. 


Paralytic  Deformities  of  the  Upper  Limb. 

Paralysis  of  the  Deltoid — The  shoulder  is  much 
flattened  and  angular,  and  in  pressing  firmly  over  the  head 
of  the  humerus  the  glenoid  cavity  can  be  felt  and  the  pro- 
jecting acromium  is  very  apparent  above  it ;  and  in  some 
cases,  if  the  arm  be  slightly  drawn  downwards,  the  finger 
can  be  passed  between  the  head  of  the  bone  and  the 
glenoid  cavity,  so  that  not  only  is  there  wasting  of  the 
deltoid,  but  also  considerable  relaxation  of  the  ligaments. 
This  affection  may  be  due  to  spinal  paralysis  or  to  injury  of 


PARALYTIC    DEFORMITIES    OF   THE    UPPER    LIMB.       427 

the  circumflex  nerve,  and  it  must  be  treated  by  frictions, 
shampooing  the  muscle,  and  the  various  forms  of  gal- 
vanism and  electricity. 

Paralysis  of  the  Serratns  Magnus. — This  muscle 
alone,  or  with  it  the  rhomboids  and  trapezius,  is  not  very 
infrequently  found  paralyzed.  The  symptoms  vary  accord- 
ing to  the  position  assumed  by  the  affected  side ;  the  disease 
may,  however,  be  bi-lateral.  When  the  arm  is  pendant  the 
scapula  of  the  affected  side  is  raised  and  is  nearer  to  the 


Pig.  217. — Paralysis  of  right  upper  limb,  showing  the  characteristic  deformity  at 
the  shoulder  and  the  wasting  of  the  arm. 


spine.  The  inferior  scapular  angle  is  higher  and  rotated 
inwards  through  the  weight  of  the  arm  and  the  action  of 
the  rhomboids  which  raise  and  fix  the  inferior  angle.  The 
posterior  border  is  more  obliquely  placed  than  natural 
through  rotation  of  the  scapula,  and  there  is  increased 
breadth  of  the  affected  side  just  above  the  posterior 
.axillary  fold.  In  some  cases  the  affected  shoulder  is  lower 
than  the  opposite  one. 

If  the  arm  be  raised  horizontally  up  and  out  in  a  line 
with  the   body,  the  scapula  is  shot  backwards  and  forms  a 


428 


BODILY    DEFORMITIES. 


prominence  in  the  dorsal  region.  When  the  arms  are 
horizontal  the  scapula  passes  up  and  backwards  without 
rotation.  This  is  due  to  the  action  of  the  trapezius  and 
levator  anguli  scapulae  unopposed  by  the  serratus.  If  the 
arms  be  brought  horizontally  forwards  so  as  to  make  the 
palms  touch,  the  dorsal  scapular  muscles,  following  the 
humerus,  drag  the  scapula  outwards,  and  its  venter  is 
exposed  and  can  readily  be  explored,  but  if  the  serratus 
were  acting  the  shoulder  blade  would  be  kept  applied  to 
the  thorax.     In  this  movement  it  will  be  found  that  the 


Fig.  218. — Paralysis  of  right  serratus  magnus. 


hand  of  the  affected  side  falls  a  good  deal  short  of  the 
other,  so  that  the  length  and  power  of  reach  are  much 
diminished.  If  the  arm  be  carried  horizontally  backwards 
the  scapula  overlaps  the  spine.  This  is  due  to  the  action 
of  the  trapezius  and  latissimus  dorsi.  In  these  movements 
the  digital  serrations  of  the  muscle  are  visible  in  moder- 
ately thin  people  on  the  sound  but  not  on  the  affected  side. 
In  raising  the  arms  in  an  extended  position  upwards  and 
forwards,  and  keeping  them  in  that  position,  it  will  be  found 
that  the  trunk  inclines  to  the  left,  and  that  this  movement 
cannot  be  fully  accomplished  without  flexing  the  fore-arm 


PARALYTIC    DEFORMITIES    OF   THE    UPPER    LIMB.       429 

on  the  arm.  The  humerus  will  also  be  much  abducted. 
In  this  movement  the  normal  scapular  rotation  on  the 
ribs  cannot  be  effected  unless  the  serratus  act  and  give 
stability  for  this  pivot-like  action.  The  scapula  becomes 
very  prominent  and  recedes  instead  of  advancing ;  it  is  also 
higher,  and  its  prominence  is  so  great  that  any  part  of  its 
whole  thickness  can  be  taken  between  the  fingers.  Some- 
times the  bone  is  so  raised  that  its  upper  border  can  be 
seen  from  the  front.  The  cyrtometer  shows  that  consider- 
able difference  exists  between  the  two  sides  of  the  chest 
during  respiration,  if  the  arms  be  raised.*  The  patient 
rarely  complains  of  pain,  except  perhaps  at  the  onset  of 
the  disease,  but  finds  the  shoulder  weak,  and  that  there  is 
pain  and  inconvenience  in  raising  it  or  in  pushing  any- 
thing. 

Causes. — It  may  be  due  to  cold,  infantile  or  other 
paralysis,  or  may  follow  typhoid  fever,  as  in  the  cases  of 
Clutton,t  Baiimler,t  and  those  of  others  which  have  been 
recorded.  I  have  seen  it  following,  and  apparently  due  to 
injury  and  also  as  a  result  of  infantile  paralysis,  and  in 
other  cases  without  obvious  cause.  It  may  also  result  from 
progressive  muscular  atrophy. 

Diagnosis. — The  altered  position  of  the  scapula  may  at 
first  sight  lead  to  the  supposition  of  lateral  curvature,  but 
the  examination  of  the  spinous  processes,  showing  them  to 
be  in  the  right  line,  and  the  fact  that  there  is  no  rotation 
and  consequent  bulging  of  the  ribs  on  the  affected  side, 
will  guard  us  against  this  source  of  difficulty.  In  the 
rarer  cases  in  which  there  is  congenital  deficiency  of 
muscles,  the  diagnosis  can  only  be  correctly  ascertained 
after  getting  an  accurate  history  of  the  case. 

*  Vivian  Poore,  Trans.  Clin.  Soc,  Vol.  8,  p.  83. 

t  St.  Thomas's  Hospital  Reports,  New  Series,  Vol.  12,  p.  176. 

%  Deutsches  Archiv  fi'tr  Klin.  Med.,  1880,  B.  25,  p.  304. 


43°  BODILY    DEFORMITIES. 

Treatment. — Galvanism  two  or  three  times  a  week  by 
means  of  the  induced  current  is  of  great  service.  The 
positive  pole  should  be  placed  over  the  spine  on  a  level 
with  the  upper  border  of  the  scapula,  and  the  negative, 
successively,  over  the  digitations  of  the  muscle.  The 
current  should  first  be  strong  and  gradually  diminished  in 
intensity.  Frictions  and  massage,  together  with  passive 
motions,  should  also  be  resorted  to.  The  prognosis  is 
generally  favourable.* 


Paralytic  Displacements  and  Dislocations  of  the 
Lower  Limb. 

In  cases  where  paralysis  has  existed  for  any  time,  or  has 
progressed  rapidly,  the  resulting  laxity  of  the  muscles  and 
relaxation  of  the  ligaments  allows  an  abnormal  degree  of 
motion  in  the  larger  joints  ;  such  as  those  of  the  ankle, 
knee,  and  hip.  The  various  forms  of  paralytic  club-foot 
have  already  been  described,  and  the  paralytic  form  of 
genu  valgum  has  been  alluded  to  in  the  chapter  on  that 
subject,  but  there  are  other  deformities  and  displacements 
at  the  knee  due  to  paralysis  ;  for  instance,  the  condition  of 
hyperextension  at  the  knee,  in  which  there  is  an  angle  at 
the  popliteal  space  instead  of  forwards  during  standing,  is 
not  very  uncommon  in  my  experience.  Paralytic  genu 
varum  may  also  be  met  with,  and  in  some  cases  the  joint 
is  so  lax  that  a  considerable  amount  of  rotation  of  the  leg 
at  the  knee  is  permissible.  It  is,  however,  only  of  late 
years  that  paralytic  dislocation  of  the  hip  has  been 
described,  though  all  surgeons  of  large  experience  must 
have  seen  such  cases,  and  orthopaedists  and  neurologists 

*  See  papers  by  Dr.  Ferrier,  Lancet,  1883,  p.  998,  and  by  J.  Dixon 
Mann,  Lancet,  1884,  February  2nd  and  9th. 


PARALYTIC   DISPLACEMENTS    OF    LOWER    LIMB. 


43  r 


must  be  familiar  with  the  very  ,lax  and  weak  condition  of 
paralyzed  hip  joints. 

Verneuil  first  drew  attention  to  the  fact  that  some  of  the 
cases  of  so-called  congenital  dislocation  of  the  hip  appear- 
ing or  becoming  evident  sometime  after  birth,  were  either 
not  really  congenital  displacements,  or  were  due  to  the  con- 


Figs.  219  and  220. — Paralytic  backward  dislocation  of  knee,  and  instrument  for 

the  same. 


genital  form  (borrowing  a  term  from  the  pathology  of  hernia) 
of  the  malady.  He  states  that  in  these  cases  there  is 
atrophy  of  the  glutei-  and  pelvi-trochanteric  muscles,  and 
that  this  is  probably  due  to  unobserved  infantile  para- 
lysis. In  these  cases  the  inactivity  of  the  adductors  whose 
action  is  unopposed  through  atrophy  of  the  glutei,  leads 
to  dorsal  dislocation,  but  in  some  instances  the  glutei-  and 


432  BODILY   DEFORMITIES. 

pelvi-trochanteric  muscles  are  intact,  while  the  psoas  and 
adductors  are  paralyzed.  These  cases  are  rare,  and  lead  to 
supra-pubic  dislocation.  When  all  the  muscles  of  the 
thigh  and  hip  are  paralyzed,  there  is  exaggerated  motion  at 
the  joint  but  no  displacement.  The  chief  cause  of  these 
dislocations  is,  undoubtedly,  the  muscular  action  of  the 
antagonists  to  the  paralyzed  muscles,  though  the  weight  of 
the  body  in  walking  further  distends  the  already  lax 
capsular  ligament  and  assists  in  the  .luxation  process. 
Infantile  paralysis,  adult  spinal  paralysis,  and  progressive 
muscular  atrophy,  all  lead  to  the  production  of  this 
deformity.  I  have  observed  and  shown  a  few  cases  of 
paralytic  coxal  dislocation  to  my  class,  and  hope  to  draw 
the  attention  of  orthopaedic  surgeons  and  neurologists  to 
these  observations  in  a  separate  paper.  The  annexed  figures 
illustrate  one  of  these  cases  and  the  instrument  worn  for 
its  relief. 

The  deformities  of  the  hand  due  to  nerve  lesions  will  be 
found  in  the  chapter  on  hand  distortions. 

Muscular  Contractions, 

The  contractions  due  to  club-hand  and  foot  are  familiar 
examples  of  this  class  of  affections,  but  the  orthopaedic 
surgeon  frequently  has  to  treat  cases  in  which  the  muscles 
of  the  limbs,  and  especially  of  the  lower  limb,  are  in  a 
contracted  condition.  In  such  spastic  cases  the  knees  may 
be  flexed  by  the  hamstrings,  or  the  thighs  approximated  by 
the  adductors,  or  flexed  upon  the  pelvis,  and  it  is  a  some- 
what common  occurrence  to  find  both  these  conditions 
associated  with  equinus.  In  the  upper  limb  contractions 
are  rarer,  though  in  cases  of  hemiplegia,  whether  juvenile 
or  senile,  one  is  not  infrequently  consulted  about  them.  In 
these,  cases  the  first  stage  of  the  deformity  as  regards  the 


MUSCULAR    CONTRACTIONS. 


433 


hand  appears  to  be  contraction  on  the  ulnar  side,  so  that 
the  hand  is  adducted.  This  position  is  favoured  by  the 
weight  of  the  hand  when  the  limb  is  held  in  its  usual 
position  with  the  radius  uppermost.  The  fingers  subse- 
quently become  much  flexed.  In  a  later  stage  the  biceps 
contracts  and  flexes  the  elbow,  and  sometimes  the  arm  is 
more  or  less  fixed  to  the  side  of  the  unused,  or  contracted, 
pectorals.     In  some  severe  or  old-standing  cases  of  lateral 


Fig.  221.— Spastic  contraction  of  flexors  and  adductors  of  thigh  and  of  the  ham- 
strings and  calf  muscles  cured  by  tenotomy  and  subsequent  treatment. 


curvature  the  latissimus  dorsi  is  found  to  be  very  tense 
when  the  patient  is  extended,  and  this  muscle  has  conse- 
quently been  divided  by  Sayre  and  others. 

Causes. — Of  these  the  most  common  are  central  nervous 
affections,  injuries,  inflammation,  reflex  spasmodic  contrac- 
tion, and  congenital  contraction.  Hysterical  contractions 
must  be  carefully  differentiated  from  these.  There  is  a 
form  of   contraction  due  to   position,   and    inflammation 

F    F 


434  BODILY    DEFORMITIES. 

which  occurs  in  the  pectorals  after  amputation  of  the  breast. 
I  have  long  been  in  the  habit  of  preventing  this  by  com- 
mencing abduction  of  the  arm  soon  after  the  operation, 
the  time  varying  according  to  the  size  and  condition  of  the 
wound.  In  old  cases  of  contraction  the  muscles  become 
degenerated  into  fatty  and  fibrous  tissue.  Rheumatism, 
syphilis,  and  gout  also  produce  muscular  contractions. 

Treatment. — In  slight  cases  manipulations,  active  and 
passive  exercises,  and  frictions,  will  generally  suffice,  but 
when  the  muscles  are  very  tense  tenotomy  is  necessary. 
In  the  upper  limb  it  may  be  necessary  to  divide  the  biceps 
for  flexed  elbow,  or  the  flexor  and  extensor  carpi  ulnaris, 
and  even  the  superficial  flexors  in  cases  of  contracted  hand. 

Tenotomy  of  Flexors  of  Wrist  and  Fingers. — The 
former  muscle  should  be  rendered  very  tense,  and  divided 
by  passing  the  knife  from  within  outwards  between  the 
tendon  and  the  brachial  artery  and  cutting  towards  the  skin. 
The  flexor  carpi  ulnaris  should  be  divided  just  above  the 
wrist,  passing  the  knife  vertically  between  it  and  the  ulnar 
artery  which  is  on  its  outer,  side,  then  cutting  towards  the 
ulnar  side.  In  dividing  the  flexors  great  care  must  be  taken 
of  the  median  nerve  if  the  operation  be  done  subcutane- 
ously,  but  if  it  be  done  by  open  wound,  a  vertical  incision, 
about  two  inches  long,  down  to  the  deep  fascia  should  be 
made  and  the  tendons  then  divided  separately,  the  nerve  held 
aside  and  the  deep  flexors  subsequently  divided,  care  being 
taken  as  the  pronator  quadriceps  is  reached  so  as  to  avoid 
wounding  the  continuation  of  the  anterior  interosseous  artery. 
The  radial  and  ulnar  vessels  must  of  course  be  carefully 
pulled  aside.  If  the  hand  be  kept  quiet  on  a  splint,  and 
the  patient  be  fairly  healthy,  there  is  no  great  risk  of  teno- 
synovitis, and  a  good  plan  is  to  apply  an  ice-bag  over  the 
bandages  for  two  or  three  days. 

In  slight  cases  of  adduction  and  flexion   of  the  thighs 


MUSCULAR    CONTRACTIONS. 


435 


and  knees,  extension  by  mechanical  apparatus,  combined 
with  passive  motions  and  massage,  may  prove  successful, 
but  it  is  commonly  necessary  to  divide  the  adductors  and 
the  hamstrings.  In  neurotic  cases  the  operation  should  not 
be  undertaken  until  all  evidence  of  active  nerve  mischief 
has  subsided. 

Tenotomy  of  Adductors  and  Hamstrings.— The 
adductor  longus  is  usually  divided  about  an  inch  from  its 
origin,  the  tendon  being  rendered  tense  by  abducting  the 
limb ;  the  surgeon's  left  hand  feels  for  the  border  of  the 


Fig.  222.— Instrument  for  use  after  tenotomy  of  adductors. 


tendon,  and  he  then  passes  the  knife  on  the  outer  side  of 
the  muscle,  and  well  beneath  it,  cutting  upwards  and  in- 
wards. If,  after  division  of  the  muscle,  other  tendons  or 
processes  of  the  fascia  lata  be  felt  tense,  they  should  be 
divided  through  the  same  puncture.  A  dossil  of  lint  is 
then  applied  under  a  bandage,  and  extension  is  usually 
commenced  on  the  third  day  after  the  operation. 

To  divide  the  hamstrings  the  patient  must  be  placed  on 
the  abdomen  and  told  to  flex  the  leg,  while  an  assistant 
gently  resists  so  as  to  bring  the  muscles  into  action ;  their 
borders  are  then  felt,  and  the  knife  passed  vertically  to  the 

F   F   2 


43^  BODILY    DEFORMITIES. 

inner  side  of  the  biceps  between  it  and  the  external  popli- 
teal nerve,  and  the  tendon  divided  outwards.  The  tenotome 
is  passed  to  the  outer  side  of  the  inner  hamstrings,  which 
are  divided  in  and  upwards.  They  may  be  tenotomized 
just  above  their  insertions,  or  near  the  upper  part  of  the 
popliteal  space.  Care  must,  of  course,  be  taken  so  as  not 
to  injure  the  popliteal  vessels  and  nerves.  After  division 
of  the  biceps  the  external  popliteal  nerve  often  stands  out, 
feeling  as  if  a  portion  of  the  tendon  were  undivided,  and 
in  severe  or  old-standing  cases  it  does  not  readily  yield, 
and  may  lead  the  inexperienced  surgeon  to  think  that  it  is 
a  portion  of  the  muscle  or  fascia,  but  on  no  account  should 
it  be  divided  until  treatment  has  shown  that  this  really  is  a 
structure  other  than  the  nerve.  The  biceps  tendon  may 
also  be  divided  by  open  incision,  and  then  the  external 
popliteal  nerve  can  be  seen  and  held  aside. 

In  rarer  cases  other  muscles  in  both  extremities  may  be 
involved  ;  such  as  the  pronators,  the  flexor  longus  pollicis, 
palmaris  longus,  and  extensors,  and  may  need  division. 
But  in  the  upper  limb  it  is  essential  always  to  give  a  fair 
trial  to  manipulations,  galvanism,  &c,  before  resorting  to 
tenotomy,  as  perfect  muscular  control  is  of  the  highest  im- 
portance in  the  upper  limb  ;  whereas  a  slight  impairment 
of  the  lower  limb  is  not  a  matter  of  any  great  moment. 
The  foot  may,  in  a  few  cases,  be  in  equinus  through  con- 
traction of  the  calf  muscles,  and  if  mechanical  means  do 
not  suffice,  the  tendo-Achillis  must  be  divided.  In  some 
other  cases  there  may  be  calcaneus  through  contracted 
extensors,  and  the  tendons  of  these  may  need  division  in 
front  of  the  ankle.  In  doing  this  the  tenotome  must  be 
•directed  away  from  the  anterior  vessels  and  nerve. 


43 


CHAPTER  XXVI. 

DEFORMITIES    OF    THE    NOSE    AND    EAR, 

The  Nose. — The  orthopaedic  surgeon,  dealing  as  he  does 
with  bodily  deformities,  is  sometimes  consulted  regard- 
ing these  affections,  and  as  the  subject  is  strictly  within  the 
province  of  orthomorphics,  and,  moreover,  as  I  have  had 
occasion  to  successfully  treat  three  cases  of  deformed  nose, 
one  in  which  the  nasal  bridge  was  depressed,  one  in  which 
these  was  a  congenitally  up-turned  nose,  and  one  in  which 
there  was  a  deep  groove  and  nez-retrousse  following  an  old 
depressed  fracture  of  the  nasal  bones,  I  wish  to  call  atten- 
tion to  the  operation  I  adopted,  as  it  has  been  a  very  ser- 
viceable one,  surgically  and  aesthetically, 

It  is  not  necessary  in  this  work  to  enter  into  deformities 
produced  by  new  growths,  nor  is  it  necessary  to  speak  at 
length  of  those  very  rare  cases  of  congenital  double-nose, 
or  bifid  nose.  Borelli  mentions  such  a  case  as  occurring 
in  a  carpenter,  but  gives  no  details.  It  may  be  that  this 
and  similar  cases  were  instances  of  hypertrophy  or  congen- 
ital tumours,  rather  than  a  veritable  second  nose.  Boyer 
mentions  the  occurrence  of  bifid  nose,  and  Verneuil* 
relates  a  curious  case  occurring  in  the  practice  of  Thomas 
of  Tours,  in  an  otherwise  well-developed  infant  of  well- 
formed   parents.     This  case  differed  essentially  from  the 

*  Bulletin  de  la  So ci£te  de  Chirzirgie,  1 8 73, 


43  8  BODILY   DEFORMITIES. 

congenital  fissure  of  the  cheek  or  upper  lip,  as  found  in 
hare-lip.  A  plastic  operation  might  be  serviceable  in  such 
cases,  and  excision  or  amputation  is  called  for  in  cases  of 
supposed  double-nose. 

Deviations  of  the  cartilaginous  septum  are  common.  If 
seen  when  the  patients  are  young,  a  properly  adjusted 
nose-machine  may  be  of  great  service,  care  being  taken  to 
avoid  inflammation  and  ulceration  of  the  skin.  If  these 
means  do  not  succeed  excision  of  a  slice  of  the  cartilage 
on  the  convex  side,  or  of  a  V_snaPed  piece,  and  suturing 
the  edges,  I  have  known  to  succeed. 


Fig.  223. — Apparatus  for  straightening  deviated  nasal  septum. 

Depression  of  the  nasal  bridge  is  usually  not  amenable  to 
treatment  unless  seen  at  the  time,  or  near  to  the  time  of  the 
injury,  when  the  passage  of  a  female  catheter  into  the  nos- 
trils, raising  the  bones  and  maintaining  them  in  position  for 
a  few  days  by  stout  rubber  tubing,  will  be  of  great  service, 
the  surgeon's  other  hand  applied  over  the  nasal  bridge 
moulding  the  comminuted  bone  over  the  firm  rubber  tubing. 
In  one  case  of  depression  of  the  nasal,  bridge  in  an  otherwise 
good-looking  young  man  I  succeeded  by  operation  in 
making  an  artificial  bridge,  and  adopted  a  similar  plan  to 


DEFORMITIES    OF   THE    NOSE    AND    EAR. 


439 


correct  the  unsightly  groove  above  an  upturned  tip  by  the 
following  operation.  The  result  of  these  cases  is  well  illus- 
trated by  the  accompanying  figures  taken  from  a  girl  aged 
eleven,  operated  on  a  few  months  since  at  the  London 
Hospital.  In  her  case  a  fall  had  broken  and  depressed 
the  nasal  bridge,  and  I  rendered  her  nose  aquiline  by  filling 
up  the  gap  between  the  bridge  and  the  tip  of  the  nose,  but 
in  the  case  of  the  young  man  just  alluded  to  I  made  an 
artificial  bridge  above  the  nasal  bones.     As  the  operation 


Fig.  224  and  225. — Depressed  bridge  before  and  after  operation. 


is  entirely  new,  a  description  of  it  will  probably  be  accept- 
able. 

Operation, — The  thumb  and  fore-finger  of  the  left 
hand  are  placed  at  the  sides  of  the  nose,  and  the  soft 
parts  thoroughly  raised  until  they  are  in  the  desired  position, 
the  nose  being  viewed  in  profile.  A  stout  needle  carrying 
a  strong  silver  wire  is  then  passed  just  above  the  fingers 
holding  the  nose.  It  is  directed  obliquely  towards  the 
mid-line,  then  depressed  and  passed  along  under  the  skin 


44°  BODILY   DEFORMITIES. 

to  a  corresponding  point  on  the  opposite  side.  About  two 
inches  of  wire  are  left  protruding  on  either  side  of  each 
puncture.  The  soft  parts  are  again  raised,  and  the 
needle  introduced  about  an  eighth  or  a  quarter  of  an 
inch  above  and  below  this  puncture,  but  the  number 
of  the  wires  passed  must  depend  upon  the  amount  of  the 
deformity.  The  ends  of  the  wires  are  then  grasped  by 
both  hands,  and  the  wires  bent  and  raised  up  in  a  curve 
so  as  to  assume  the  desired  shape.  The  ends  are  cut  off, 
leaving  a  quarter  of  an  inch  projecting,  and  these  are  pro- 
tected by  oiled-lint.  The  immediate  result  is  most 
satisfactory,  and  is  due  not  only  to  the  shape  given  to  the 
wires  but  to  blood-clot  forming  around  them.  This  sub- 
sequently becomes  organized,  and  forms  a  prominent  bridge 
around  the  wires,  which  must  be  left  permanently  in  place. 

In  the  first  case  I  removed  one  of  the  wires  a  month 
after  the  operation,  to  observe  the  effect,  and  found  that  in 
a  comparatively  short  time  absorption  had  taken  place,  so 
that  the  result,  though  a  very  great  improvement,  was  not 
so  satisfactory  as  when  the  wires  are  left  in  place.  The 
ends  of  the  wires  may  subsequently,  or,  if  desired,  at  the 
time  of  the  operation,  be  cut  short  and  buried  through  the 
same  puncture  and  left  in  position ;  but  I  have  preferred 
leaving  this  to  a  later  stage  of  the  treatment,  in  case  a 
further  elevation  of  the  depression  by  means  of  the  wire 
became  necessary. 

I  had  thought  of  attacking  the  bones  in  the  following 
way,  and  this  plan  will  be  useful  in  some  cases.  Two 
incisions,  one  on  each  side  of  the  nose,  running  obliquely 
from  above  down  and  out  were  to  be  made,  and  the  soft 
parts  raised  with  an  elevator,  the  cartilage  was  to  be  then 
separated  from  the  bones  and  small  cutting  forceps  used 
so  as  to  isolate  the  nasals  from  the  superior  maxillse  and 
frontal,   and  the  bones  were  then  to  be  replaced  with  a 


DEFORMITIES    OF   THE    NOSE    AND    EAR.  44 1 

pair  of  forceps,  the  blades  of  which  were  to  be  protected 
with  india-rubber  so  as  not  to  injure  the  skin.  Stout 
rubber  tubing  was  to  be  introduced  through  the  nostrils  to 
keep  the  bones  in  place  and  for  drainage.  If  needful,  one 
or  two  stout  hare-lip  pins  were  to  be  passed  through  the 
incisions  and  under  the  bones,  and  these  were  to  be  sup- 
ported laterally  by  oiled  pads  kept  in  place  by  a  nasal  truss 
like  that  shown  in  the  first  figure  of  this  chapter.  The 
skin  incisions  were  first  to  be  brought  together.  Mr. 
Walsham  has  devised  and  figured  an  apparatus  which  he 
says  will  rectify  displaced  bones  as  well  as  cartilages ;  but  it 
seems  to  me  that  the  skin  would  ulcerate  before  any  im- 
pression could  be  made  on  the  bones.  His  paper  is  in  the 
Lancet  for  September  20  of  this  year. 

The  Ear. — The  deformities  of  the  external  ear  which 
admit  of  surgical  treatment  are  not  numerous.  Supernu- 
merary auricles  must  be  removed.  Contracted  meatus  must 
be  treated  according  to  the  condition  and  cause,  and  works 
on  aural  surgery  must  be  consulted  for  these.  But  there 
are  two  conditions  of  the  ear  which  are  oftenest  seen  and 
best  treated  in  children,  and  which  have  come  under  my 
notice  at  the  East  London  Children's  Hospital  and  on  a 
few  occasions  in  private.  I  allude  to  external  and  forward 
projection  of  the  auricles,  and  also  to  the  occurrence  of  large 
flap-like  or  dojikey-ears.  The  former  condition  is  best 
treated  in  infants  by  a  piece  of  strapping  passing  from 
the  zygomatic  arch  on  one  side  over  the  auricles  to  a 
similar  position  on  the  other,  and  if  this  plan  be  com- 
menced from  infancy  and  continued  for  some  months,  the 
mal-position  of  the  auricles  can  be  remedied.  Later  in  life,  a 
light  elastic  spring  attached  to  two  vulcanite  flesh-coloured 
ears  fixed  over  the  natural  ones  and  passing  beneath  the 
hair,  should  be  worn  for  a  long  time,  and  then  the  position 
of  the  cartilages  will  be  considerably  improved.     In  some 


442 


BODILY   DEFORMITIES. 


cases  the  ears  are  too  closely  set,  or  the  lobule  is  adherent 
to  the  skin  in  part,  or  in  whole.  In  the  former  case  division 
of  the  external  aural  muscles  may  be  of  service,  and  in 
the  latter  an  incision,  or  plastic  operation,  may  be  required. 
In  cases  where  the  auricle  is  turned  forwards  so  as 
to  close  the  meatus,  tense  bands  of  skin  or  of  cicatrix,  if 


Figs.  226  and  227. — Martino's  operation  for  large  and  prominent  ear. 


these  have  caused  it,  must  be  divided,  and  the  ear  main- 
tained in  position  for  some  time  after  healing  of  the  wounds 
has  taken  place.  In  hypertrophy  of  the  external  ear,  or, 
in  cases  in  which  it  is  very  large,  Martino  has  excised 
a  triangular  piece,  and  subsequently  carefully  sutured 
the  edges,  as  shown  in  the  accompanying  figures,  with  a 
good  result. 


443 


CHAPTER   XXVII. 

CONTRACTIONS    AND    DEPRESSED    CICATRICES. 

Causes.— These  terms  sufficiently  explain  themselves,  and 
are  due  to  destructions  of  the  skin  and  subcutaneous  tissue, 
sometimes    involving    the    deep  fascia,   caused  by  burns, 
lacerations,  and  gangrene  of  the  skin.     In  deep   cutaneous 
destructions  the    wound  is    repaired  by  fibrous  material, 
which  is  highly  contractile,  and   so  powerful  is    this  con- 
traction in  some  instances  that  joints  may  be  displaced, 
bones— especially  of   young   subjects— may  be  distorted, 
and,  of  course,  important  soft  structures  dislocated  and 
sometimes  involved  in  the  cicatrix,  as  I  have  seen  them 
in  cases  of  severe  burn  of  the  neck.     Every  general  and 
orthopaedic  surgeon   of  experience  must  have  seen  cases 
of  severely  deformed  limbs   due  to  cicatrical  contraction 
resulting  from  severe  burns,  or  extensive  lacerations,  and 
as  such  cases  are  difficult  to  treat  satisfactorily  and  require 
much  patience,  I  will  devote  a  little  space  to  their  considera- 
tion.    It  must  be  borne  in  mind,  however,  that  the  growth 
of  cicatrices,  especially  of  the  less  severe  forms,  coincides 
with  that  of  the  affected  part,  and  in  the  milder  cases 
there  is  some  hope  from  this  fact ;  but  in  the  deeper  forms  of 
burn,  contraction  completely  overcomes  expansive  growth. 
Treatment— In   treating   cases   of  extensive  or  deep 
destruction  of  the  skin  and  subcutaneous  tissues,  the  main 


444  BODILY   DEFORMITIES. 

object  should  be  to  prevent  contraction  as  much  as 
possible  and  to  expedite  healing ;  but  it  is  inadvisable  to 
extend  without  due  care,  as  the  healing  process  is  interfered 
with,  and  the  ultimate  contraction  becomes  severe.  But 
when  cicatrisation  has  taken  place  extension  should  be 
perseveringly  insisted  in,  so  that  the  new  and  supple 
cicatrix  may  be  brought  into  a  proper  condition  and  posi- 
tion, as  old  cicatrices  are  very  slightly  extensile.  Multiple 
skin  grafting  should  always  be  attempted  in  cases  of 
severe  destruction  of  the  skin,  as  it  is  thought  that  the 
grafted  epithelium  gives  to  the  cicatrix  a  more  supple 
character. 

Extension  should  be  gradual  and  constant,  and  it  is  well 
to  accompany  this  by  frequent,  active,  and  passive  move- 
ments. A  properly  adjusted  instrument  should  be  con- 
stantly worn,  and  gentle  frictions  with  oil  and  careful 
massage  of  the  new  tissue  are  often  of  service.  If  these 
means  fail,  and  contraction  increase  to  the  production  of 
deformity,  operative  measures  must  be  resorted  to,  and  these 
will  vary  according  to  the  condition  present. 

Operations.— The  object  to  be  attained  is  to  get  a 
lengthening  of  the  contracted  part,  and  this  is  generally  done 
by  subcutaneous  or  open  division  of  the  cicatricial  tissue, 
care  being,  of  course,  taken  that  no  important  vessels  or 
nerves  are  divided  with  the  cicatrix.  When  the  gap  is 
filled  up  there  is  that  much  new  tissue,  but  it  must  be 
recollected  that  this  has  a  strong  tendency  to  contract,  so 
that  unless  extension  be  continued  for  a  long  time  the 
deformity  will  be  but  little  improved.  If  the  cicatrix  be  a 
band,  fold,  or  web,  it  may  be  treated  by  making  a  perfora- 
tion at  its  base,  and  subsequently  dividing  the  tissues  and 
keeping  them  well  apart,  as  in  one  form  of  operation  for 
webbed  digits. 

Another  plan  is  to  dissect  up  the  new  and  imperfectly 


DEPRESSED    CICATRICES.  445 

formed  skin,  to  dissect  out  the  fibrous  bands  underneath, 
then  to  forcibly  stretch  or  overstretch  the  parts,  sub- 
sequently bringing  the  linear  skin  wounds  together  and 
keeping  the  parts  extended  during  the  healing  process. 
Another  method  is  to  transversely  divide  the  scar  tissue, 
stretch  the  parts  into  position,  and  bring  the  edges 
together  as  much  as  possible,  so  as  to  lengthen  the  scar ; 
or  the  wound  may  be  left  open  and  skin  may  be  grafted 
on  the  surface  as  soon  as  granulations  appear. 

Transplantation  of  skin  from  the  neighbourhood  of  the 
cicatrix  or  from  distant  parts  has  sometimes  succeeded. 
It  is  desirable,  as  pointed  out  by  Mr.  John  Wood,  so  to 
form  the  flap  that  it  can  be  turned  in  the  course  of  distinct 
subcutaneous  arteries.  It  is  well  not  to  transplant  large 
pieces  of  skin,  as  in  the  event  of  failure,  especially  if  the 
skin  has  been  taken  from  near  the  cicatrix,  the  deformity 
is  increased  instead  of  benefited. 


Depressed  Cicatrices. 

When  these  occur  in  exposed  positions,  as  on  the  face, 
neck,  upper  part  of  the  chest,  &c,  they  produce  unsightly 
conditions,  which,  especially  in  females,  are  of  a  mentally 
depressing  nature.  Such  scars  are  commonly  due  to 
strumous  inflammations  and  abscesses  of  the  cervical 
lymphatics,  or  to  gum  boils  and  alveolar  abscesses  opening 
on  the  cheek.  They  may  also  be  due  to  various  injuries, 
followed  by  inflammation. 

Treatment.— Formerly,  the  deep  adhesions  were  se- 
parated by  a  fine  knife,  and  it  was  thought  that  the  blood 
effused,  which  immediately  after  the  operation  raised  the 
cicatrix,  would  become' organized  and  so  do  away  with  the 
depression,  but  very  often  the  blood  became  absorbed  and 
the  depression  returned  and  probably  increased  as  the  new 


446  BODILY   DEFORMITIES. 

tissue  contracted.  Mr.  W.  Adams  has  devised  a  plan  by 
which  he  subcutaneously  divides  all  adhesions,  then 
thoroughly  everts  the  depressed  skin,  so  that  the  cicatrix 
remains  raised ;  he  then  passes  two  hare-lip  pins  at  right 
angles  through  the  base  of  the  cicatrix,  and  retains  them  in 
position  for  three  days.  He  expresses  himself  as  satisfied 
with  the  result  of  this  operation.  Not  being  satisfied  with 
cases  operated  on  by  this  method,  because  of  the  sub- 
sequent greater  or  less  reappearance  of  the  depression  in 
consequence  of  absorption  or  contraction  of  the  new 
material,  I  have  adopted  a  plan  varying  a  little  from  that 
described  in  the  chapter  on  nasal  depression.  It  consists 
in  passing  a  silver  wire  subcutaneously  around  the  adhesions, 
making  the  ends  emerge  at  the  same  puncture  and  tightly 
drawing  and  twisting  the  ends  together.  The  adhesions, 
are  thus  more  or  less  cut  through  at  the  time  of  the  opera- 
tion, and  by  giving  an  extra  twist  occasionally,  the  re- 
mainder of  them  will  give  way.  The  ends  are  then  cut  off 
close  to  the  puncture  and  buried  in  it,  and  the  wire  left 
permanently  in  situ.  The  new  material  thrown  out  as  a 
result  of  the  operation  becomes  organized  around  the  wire, 
and  the  two  together  prevent  the  cicatrix  relapsing. 


APPENDIX. 


OSTEOTOMY  FOR  IRREMEDIABLE  EQUINUS. 

Some  years  ago,  in  a  case  of  badly  united  fracture  of  the 
tibia  in  which  the  foot  was  fixed  in  equinus,  I  corrected  the 
deformity  of  the  leg  and  malposition  of  the  foot  by  a  supra- 
malleolar osteotomy  and  tenotomy  of  the  tendo-Achillis,  and  it 
has  occurred  to  me  to  try  this  plan  in  a  case  of  extreme  neg- 
lected equino-varus  now  under  treatment  at  the  London 
Hospital. 

Whether  the  idea  be  original  or  novel,  I  cannot  say,  but  it 
appears  to  be  a  proper  and  hopeful  proceeding  in  otherwise 
irremediable  cases  of  equinus,  and  much  preferable  to  excision 
or  osteotomy  of  the  astragalus  which,  of  necessity,  leaves  a 
rigid  foot. 


TREPHINING  IN  POTT'S  DISEASE. 

Dr.  McEwen,  of  Glasgow,  has  opened  the  spinal  canal  and 
removed  inflammatory  material  pressing  on  the  cord.  I  do 
not  know  of  any  detailed  publication  of  his  cases,  and  cannot, 
of  my  own  experience,  say  anything  as  to  whether  the  pro- 
ceeding is  likely  to  find  a  permanent  place  in  Surgery.  I  do 
not,  however,  doubt  that  some  cases  may  justify  the  operation, 
both  from  the  urgency  of  their  symptoms  and  the  ultimate 
history  of  the  cases.  At  first  sight  it  seems  to  me  that  the 
spinal  canal  must  remain  weakened,  but  until  we  know  more  of 
McEwen's  cases  and  manner  of  operating,  judgment  must  be 
withheld. 


448 


APPENDIX. 


ABSENCE  AND    DEFICIENCY   OF    CLAVICLES. 

The  clavicles  may  be  partially  or  wholly  absent.  I  have  seen 
three  instances  of  this  deformity,  and  two  were  in  males.  In 
one  case,  seen  also  by  Mr.  Eve,  at  the  London  Hospital,  the 
inner  third  of  both  clavicles  was  undeveloped,  and  the  free  ends 
formed  prominences.  In  another  case  the  deficiency  was 
unilateral,  the  inner  half  being  deficient.  In  the  third  case, 
occurring  in  a  girl,  the  outer  fourth  or  fifth  of  the  bones  was 


Fig.  228. — Absence  of  clavicles,  showing  how  the  arms  may  be  tied  together. 

(Kammeler.) 


represented  by  ligamentous  tissue,  which  could  be  felt  on  move- 
ment and  manipulation.  In  these  cases  much  greater  forward 
and  backward  movement  of  the  arms  is  possible,  and  the  extent 
of  this  will  vary  with  the  amount  of  the  deformity.  Proper 
exercises  and  instrumental  treatment,  if  begun  early,  will  do 
much  to  obviate  the  results  of  the  deficiency. 


DUPUYTREN'S  CONTRACTION. 

During  the  past  few  months  I  have  had  under  observation 
five  cases  of  this  deformity.  Two  were  in  females  and  three  in 
males.  Of  the  former,  I  showed  one  case  to  the  class  at  the 
London  Hospital.     It  occurred  in  a  washerwoman,  aged  52, 


APPENDIX.  449 

and  she  attributed  it  to  wringing  clothes,  but  seeing  that  it 
affected  her  left  hand,  and  no  pressure  of  any  sort  came  on  it 
during  this,  and  that  both  hands  are  used  simultaneously  for 
this  purpose,  her  explanation  does  not  seem  satisfactory.  There 
was  no  evidence  of  gout  or  rheumatism. 

I  have  recently  operated  on  a  lady  aged  45,  in  whom  the 
affection  began  at  the  age  of  32.  The  right  ring-finger  was 
much  bent,  and  the  adjoining  fingers  were  becoming  drawn  in 
through  processes  at  their  webs.  She  thinks  it  may  have  been 
produced  through  falling  from,  and  being  dragged  some  distance 
by,  a  horse  while  holding  the  reins.  Shortly  after  that  she  took 
a  hobby  for  a  sewing-machine,  which  she  worked  a  good  deal, 
and  being  fond  of  music  practised  very  often  on  a  digitorium. 
I  operated  by  Hardie's  modification  of  Goyrand's  method, 
excised  the  greater  part  of  the  tense  band,  and  the  finger  became 
straight  after  two  loudish  snaps,  which  were  doubtless  caused  by 
some  deeper  fibres  being  ruptured.  I  was  able  perfectly  to 
straighten  the  finger,  and  the  case,  up  to  date,  has  done 
admirably,  for  the  wound  healed  by  first  intention. 

Of  the  three  cases  occurring  in  males,  one  came  under  notice 
at  the  London  Hospital,  and  two  were  private.  The  former 
occurred  in  a  man  aged  31,  a  hatter  from  Nottingham,  and 
occupied  the  right  ring-finger.  He  declined  treatment.  One 
of  the  private  cases  was  a  gentleman  aged  60,  who  had  observed 
a  thickening  of  his  left  palm  for  about  ten  years,  and  attributed 
it  to  the  pressure  of  his  walking-stick,  which  he  usually  carries 
in  his  left  hand.  There  is  a  tense  band,  not  very  prominent, 
and  a  nodule  at  the  proximal  end  of  the  palmar  aspect  of  the 
metacarpal  phalanx.  The  condition  remains  stationery,  and  so 
I  did  not  advise  operation.  It  is  well  to  recollect  that  some  few 
cases  are  of  this  nature.  His  habits  as  regards  living  are  some- 
what free. 

The  last  case  is  unique  in  my  experience  and  reading.  The 
subject  of  it  is  a  boy  aged  12.  His  left  hand  has  a  distinct 
band  to  the  middle  finger  and  some  nodules  in  the  palm,  but  in 
the  right  hand  the  scattered  nodules  are  more  noticeable  than 
the  bands,  which  are  quite  rudimentary  as  yet.  The  fingers 
are  slightly  bent,  and  complete  extension  is  impossible.  At 
present  operation  is  not  called  for,  so  I  have  ordered  inunc- 

G   G 


450  APPENDIX. 

tions,  manipulations,  and  a  light  machine,  which  Mr.  Schramm 
is  making  for  him. 

Dupuytren's  contraction  occurring  at  this  early  age,  and  in  a 
child  whese  parents  are  free  from  gout,  and  who  has  never 
had  any  great  pressure  on  his  palms,  is  a  pathological  rarity 
worthy  of  permanent  record. 


INDEX. 


Abbe,  Dr.  R.,  361. 

Abdomen,  deformities  of,  80 ; 
diagnosis,  80 ;  pendulous,  80  ; 
belt  for,  81  ;  and  protuberant 
before  and  after  application  of 
corset,  82 ;  symptoms,  80 ; 
treatment,  81. 

Acquired  deformities,  3. 

Adams,  22,  156,  198,  202,  222, 
234,  263,  354,  362,  364,  366, 
368,  370,  371,  412,  446. 

yEsterlen,  282. 

Albucasis,  261. 

Anatomy,  essentials  of  spinal,  21. 

Anchylosis  and  unreduced  dislo- 
cations, 383 ;  ankle,  406 ; 
causes,  384 ;  rheumatic  of 
knees,  386  ;  severe  false,  of  hip 
and  knee  after  rheumatism, 
384 ;  definition,  383 ;  diag- 
nosis, 398  ;  elbow,  405  ;  forcible 
correction  of,  402  ;  hip,  409  ; 
bony,  before  and  after  opera- 
tion, 416 ;  and  contracted 
knees,  409,  413  ;  cross-shaped 
after  morbus  coxae,  41 1  ;  opera- 
tions for  angular,  of  knee,  415  ; 
formation  of  new  joint  near, 
414  ;  osteotomy,  lines  for,  412  ; 
in  fusion  of  both  bones,  412  ; 
jaw,  415  ;  treatment,  417  ;  joints 
of  the  hand  and  foot,  418 ;  knee, 
406  ;  in  fraction  of  tibia  into 
cancellous  tissue,  &c,  408; 
subluxation  in  attempted  reduc- 


tion, 408 ;  pathology,  387  ; 
lengthening  of  lower  end  of 
femur  in  chronic  arthritis,  390  ; 
position  of  bones  in  a  case  of 
bony  anchylosis  at  knee,  391 ; 
scrofulous  bony,  after  morbus 
coxae,  387  ;  prognosis,  400 ; 
shoulder,  404  ;  symptoms,  398  ; 
synonyms,  383  ;  tenotomy,  410  ; 
treatment,  401  ;  instruments  for 
gradual  correction  of  elbow 
and  wrist,  402  ;  varieties,  383  ; 
wrist  and  fingers,  405. 

Andry,  115. 

Annandale,   235,    261,  263,  264, 
265,  342,  411. 

Apelles,  282. 

Archimedes,  282. 

BACKEL,  J.  AND  E.,   I44. 

Baginsky,  12. 

Baker,  116,  252. 

Barbarin,  259. 

Barber,  257. 

Barberia,  257,  259. 

Barker,  264,  316. 

Bartez,  421. 

Barton,  262,  413,  414. 

Barwell,    26,    70,    71,    235,   261, 

264,  414. 
Bauer,  403. 
Baum,  356,  358. 
Baiimler,  429. 
Beaurigard,  259. 
Beclard,  150. 

G   G    2 


45  2 


INDEX. 


Bell,  Sir  C,  87. 

Belt  for  pendulous  abdomen,  Si. 

Berger,  374,  377,  3§2. 

Bernard,  C,  Sj. 

Bernhardt,  376. 

Billroth,  135,  261,  263,  265,  3S9. 

Bird,  G.,  202. 

Blasius,  234,  282. 

Boeckel,  259. 

Bonnet,  149,  234,  252,  3S9. 

Borelli,  347- 

Bosch,  2S2. 

Bouiand,  107. 

Bouvier,  37,  70,  93,  107,  120,  197, 

309- 
Boyer,  321,  437. 
Brainard,  262,  263. 
Breschet,  151,  294. 
Broca,  151,  294,  314,  371. 
Brodhurst,    234,    263,    294,   296, 

29S,  309,  403,  404. 
Bryant,  170,  172,  367. 
Bruce,  386. 
Bruns,  282. 
Buck,  G.,  414. 
Buehring,  25,  26,  69. 
Bunions,  324. 
Busch,  170,   246,   35S,   360,  363, 

364,  365>  374,  397- 
Butlin,  385. 

C^sar,  Julius,  144. 

Calcaneus,  acquired,  220  ;  causes, 
220 ;  excision  and  suture  of 
parts  of  elongated  tendons, 
223 ;  morbid  anatomy,  221  ; 
prognosis,  222 ;  symptoms, 
220  ;  paralytic,  221 ;  treatment, 
222 ;  instrument  for  severe, 
223  ;  congenita],  218  ;  degrees, 

218  ;     pathological     anatomy, 

219  ;  symptoms,  218  ;  six-toes 
with  second  and  third,  and 
fourth  and  fifth  webbed,  219  ; 
talipeSj  218;  definition,  218; 
varieties,  218. 

Callender,  144. 
Campenon,  261,  264. 
Camper,  124.  312. 
Caries,  spinal,  124  ;  causes,  124  ; 
definition,  124;  diagnosis,  137; 


instruments,  141  ;  supports  for 
lumbar,  141,  143  ;  pathology, 
135  ;  how  straightened  by  in- 
struments, 130  ;  prognosis,  139; 
lower  dorsal  and  slight  right 
morbus  coxae,  130  ;  lumbo- 
sacral and  severe  angular  de- 
formity, 132;  synonyms,  124; 
surgical  treatment,  144  ;  pos- 
terior incision  of  abscesses,  144; 
treatment,  139  ;  suspensory 
cradle,  140 ;  supports,  141  ; 
varieties,  124. 

Carnochin,  294,  298. 

Cavus  pes,  225  ;  causes,  225  ; 
definition,  225  ;  impression  of 
a  sole,  225  ;  pathological 
anatomy,  226  ;  symptoms,  226 ; 
left  foot,  226  ;  synonyms,  225  ; 
treatment,  226  ;  varieties,  225. 

Celsus,  409. 

Champreys,  304. 

Chance,  150,  209. 

Chiari  tend,  243. 

Charnier,  246. 

Chassaignac,  394. 

Chaussieur,  147,  148,  151. 

Chavasse,  145. 

Chiene,  145,  235,  261,  263,  265. 

Chondrotomy,  epiphysial,  281. 

Cicatrices,  depressed,  445  ;  treat- 
ment, 445. 

Clemot,  262. 

Club-foot  or  talipes,  146  ;  causes, 
149  ;  classification,  149  ;  com- 
pound forms  of,  230  ;  relative 
frequency,  147  ;  synonyms,  146; 
varieties,  146. 

Club-hand,  326  ;  definition,  326  ; 
synonyms,  326  ;  varieties,  326  ; 
acquired,  334;  causes,  334; 
prognosis,  335  ;  symptoms  and 
diagnosis,  334  ;  treatment,  335  ; 
congenita],  327  ;  causes,  327  ; 
classification,  nomenclature  and 
symptoms,  329  ;  cubito-palmar, 
331  ;  dorsal,  331  ;  left  radio- 
palmar,  lower  part  of  radius 
and  thumb  absent,  330  ;  patho- 
logical anatomy,  327  ;  double 
hands  and  feet  in  same  infant, 


INDEX. 


4-  -> 
DO 


328  ;  radio-palmar,  the  thumb 
'  absent,  329,  330. 

Club-hand,  congenital,  tenotomy, 
332  ;  treatment,  332. 

Clutten,  429. 

Colin,  260,  2S2. 

Condylotomies,  280 ;  internal, 
272. 

Congenital  deformities,  2  ;  mal- 
position of  hip,  292. 

Contractions,  muscular,  432  ; 
spastic  of  flexors  and  adductors 
of    thigh,    &c,    433;    causes, 

433  ;  tenotomy  of  adductors 
and  hamstrings,  435  ;  instru- 
ment for  use  after,  435  ;  of 
flexors    of    wrist   and    fingers, 

434  ;  treatment,  434  ;  and  de- 
pressed cicatrices,  443  ;  causes, 
443  ;  operations,  443. ;  treat- 
ment, 443  ;  of  the  palmar 
fascia,  353. 

Cooper,  Sir  A.,  367. 

Cooper,  B.,  367. 

Corns,  324. 

Coulomb,  108. 

Cruveilhier,  294. 

Cucherilli,  261. 

Cuneiform  osteotomy,  279  ;  tar- 
sotomy, 171. 

Curvatures  of  the  spine,  30  (see 
spine). 

Curved  tibia  and  fibula,  289. 

Cyphosis,  106  ;  causes  and  seat, 
107  ;  definition,  106  ;  diag- 
nosis, in;  pathology,  108; 
prognosis,  113;  spinal  correc- 
tors and  supports,  U5;Myrop's 
applied;  debility,  116;  appar- 
atus for,  117;  symptoms,  109; 
treatment,  severe  upper  dorsal, 
Hi;  synonyms,  106;  treat- 
ment, 114  ;  dorsal  cyphosis  be- 
fore and  after  application  of 
spring  contractor,  114;  varie- 
ties, 106. 

Czemy,  10. 

Daechamps,  261. 
Dally,  294. 
Davis-Colley,  170,  171. 


Davy,    Dr.    R.,    149,    i~o,    171, 

175- 

Dece,  343. 

Deformities — definition  of,  I  ; 
ear,  441  ;  general  remarks  on 
causes,  2 ;  lower  limb  (condyl- 
otomies), 280;  nervous,  421; 
nose.  437  ;  prophylaxis  of,  6  ; 
scope,  1  ;  spine  and  trunk,  21  ; 
upper  limb  (condylotomies), 
281. 

Delore,  113,  236,238,  256,  257, 
258,  259,  260,  274. 

Delpech,  52,  150. 

De  Watteville,  69. 

Didot,  341. 

Dieffenbach,  91. 

Digital  deformities,  acquired, 
347;  causes,  347  ;  diagnosis, 
349  ;  lateral  deviation  of  fin- 
gers, 349  ;  displaced  left  inde: 
and  middle  ungual  phalanges, 
349  ;  wasted  hand,  349  ;  mus- 
cular and  nervo-muscular  affec- 
tions, 348  ;  contractions  of  fin- 
gers, 348  ;  flexors  from  infantile 
paralysis,  348  ;  extensors,  348  ; 
tenotomy  of  flexors,  351  ;  to 
divide  the  superficial  flexor, 
35 1 ;  mechanical  pen  for  writers 
paralysis,  351  ;  to  divide  the 
gauntlet  for  same,  351  ;  treat- 
ment, 350  ;  apparatus  for  elas- 
tic extension  of  contracted 
fingers,  350  ;  writer's  or  Scriv- 
ener's palsy,  351. 

Dislocations  of  the  lower  limb, 
340  ;  unreduced,  418  ;  com- 
plications, 419  ;  treatment, 
418. 

Displacements  (paralytic)  of  the 
lower  limb,  340. 

Dubreuil,  148,  313. 

Duchenne,  86,  89,  116,  120,  190, 
220,  234,  334. 

Dupuytren,  293,  294,  337.  349, 
356,  357.  359,  363,  366,  3$7- 

Duret,  392. 

Duval,  147,  148,  149. 

Duverney,  150. 


454 


INDEX. 


Eantrikin,  414. 

Ear,  deformity  of,  414  ;  Martino's 
operation  for  large  and  promi- 
nent, 442. 

Encephalocele,  occipital,  322. 

Equino-valgus  (pes)  —  valgus, 
181  ;  congenital,  182 ;  defini- 
tion, 181  ;  degrees,  182;  path- 
ological anatomy,  182  ;  syno- 
nyms, 181  ;  varieties,  181  ; 
left  foot,  181. 

Equino-varus  (pes),  152  ;  ac- 
quired, 159;  causes,  159  ;  con- 
genital, 153;  degrees  of  de- 
formity, 158;  pathological 
anatomy,  153  ;  articulations, 
155;  bones,  154;  fasciae,  155; 
ligaments,  155;  muscles,  156; 
congenital,  pathological,  nor- 
mal foot  and  one  in,  155  ; 
tendons,  156;  synonyms,  152; 
paralytic,  160;  after  treatment, 
165  ;  Baker's  scarpa  for  severe 
cases,  160  ;  the  instrument  ap- 
plied, 161  ;  shoe  for  severe 
cases,  168  ;  scarpa  with  mov- 
able sole-plate,  168  ;  prognosis, 
161  ;  tenotomy,  162 ;  sharp 
tenotomes,  163  ;  outer  and 
inner  views  of  universal  scarpa, 
164 ;  scarpa  shoe  for  severe 
cases,  165  ;  treatment,  161  ; 
immediate  rectification  of  ex- 
treme, 175  ;  amputation,  175  ; 
double  congenital  neglected, 
176. 

Equinus  (pes),  205 ;  acquired, 
206  ;  causes,  206  ;  definition, 
206  ;  degrees  and  varieties, 
206 ;  congenital  neglected,  207 ; 
diagnosis,  212  ;  division  of  the 
plantar  fascia,  no;  excision  of 
the  astragalus,  216  ;  pathologi- 
cal anatomy,  208;  aggravated 
form  with  toes  flexed,  208 ; 
bones,  208 ;  ligaments,  209 ; 
muscles,  209  ;  ordinary  forms 
of,  208  ;  prognosis,  214  ;  symp- 
toms, 210 ;  severe  forms  of, 
211  ;  treatment,  214;  congen- 


ital,    205  ;     definition,     205  ; 

symptoms,     205  ;     congenital, 

varieties,  205. 
Erichsen,  179. 
Eschricht,  151. 
Esmarch,  266,  282,  417. 
Eulenburg,  71. 

Felicki,  375. 

Fergusson,  Sir  W.,  363,  364, 
.368. 

Fibula  and  tibia,  curved,  289  ; 
treatment,  289 ;  before  and 
after  osteotomy,  289. 

Fieber,  374.' 

Finger,  jerk,  snap,  or  spring, 
373  ;  causes,  373  ;  definition, 
373  ;  pathogenesis,  380  ;  gan- 
glion of  flexor  tendons  of 
index,  380 ;  pathology,  374  : 
prognosis,  381  ;  symptoms, 
373  ;  synonyms,  373  ;  treat- 
ment, 381. 

Fingers,  deformities  of,  336  ;  ac- 
quired, 340  ;  cause,  340 ; 
stunted  and  webbed  hand,  340  ; 
operation  by  a  permanent  open- 
ing at  base  of  the  web,  340  ; 
Dece,  343  ;  Didot,  341  ;  Nor- 
ton, 343  ;  feller,  342  ;  treat- 
ment, 340  ;  congenital,  337  ; 
causes,  336  ;  contractions,  345  ; 
defective  and  partly- webbed  of 
left  hand,  345 ;  deficiencies, 
344  ;  lateral  deviation,  347  ; 
hypertrophy,  345  ;  defective 
and  deformed,  from  encephalo- 
cele, 346 ;  treatment,  346  ; 
polydactylism,  337  ;  abortive 
thumb  and  supernumerary 
digit,  338  ;  syndactylism,  339  ; 
bifurcated  hand,  no  thumb, 
339  ;  treatment,  338  ;  varieties, 

336. 

Fochier,  259. 

Gabriel,  375. 
Ganglions,  324. 
Gant,  263,  413. 
Gay,  J.,  364. 


INDEX. 


455 


Genu  valgum,  232  ;  causes,  232  ; 
complications,  246  ;  definition, 
232 ;  degrees,  240  ;  forcible 
manual  reduction,  256  ;  a  case 
of  atonic  double,  &c,  253,  25S  ; 
instrumental  reduction,  260 ; 
measurement  of  the  deformity, 
24S ;  instruments  for,  251,  252; 
of  amount  of,  249,  250  ;  mor- 
bid anatomy,  241  ;  diagram  of 
normal  and  abnormal  femur, 
242  ;  prognosis,  249 ;  symp- 
toms, 243  ;  on  flexion  disap- 
pearance of,  246  ;  shortening 
caused  by,  244 ;  synonyms, 
232  ;    tenotomy  of  the  biceps, 

253  ;  treatment,  249  ;  varieties, 
232. 

Genu  varum,  284  ;  causes,  284  ; 
definition,      284 ;      pathology, 

254  ;  genu  extorsum  before  and 
after  diaphysial  osteotomy.  287  ; 
symptoms,  2S7  ;  severe  before 
and  after  external  condylotomy, 
2S8 ;  synonyms,  284  ;  treat- 
ment, 288  ;  varieties,  2S4. 

Geoffray,  151. 

Gerard,  246. 

Gibney,  Dr.  V.  P.,  138. 

Gooch,  91. 

Goodsir,  245. 

Gosselin,  195,  236. 

Goyrand,    322,    356,     357,     363, 

371. 

Grant,  396. 

Gross,  414. 

Gueniot,  243,  246,  304. 

Guerin,  35,  71,75,  76>  IO°,  I5°» 

190,  234,  252,  298,  372. 
Guerin,   J.,    87,    150,    294,  367, 

372. 
Gymnastics,  7. 

Hahn,  174,  374. 

Haller,  87. 

Hallux  valgus,  312  ;  varus,  317. 

Hammer-toe,  311,  319,  320. 

Hassard,  71,  72,  75. 

H award,  264. 

Hawkins,  Caesar,  363,  364. 

Henke,  1S6,  187. 


Henle,  245. 
Hill,  D.,  347. 
Hilton,  124,  416. 
Hingston,  Dr.  W.  H.,  177. 
Hip,   congenital  malpositions  of, 

292  ;  causes  and  pathogenesis, 

293  ;  displacements  of,  293, 
297,  300  ;  complications,  305  ; 
definition,  292  ;  diagnosis,  306  ; 
double  in  a  woman  who  had 
had  children,  307  ;  prognosis, 
308  ;  symptoms.  300  :  right  hip 
in  an  infant,  302  ;  treatment, 
308  ;  instrument  for,  309 ; 
varieties,  292. 

Hippocrates,  261,  282,  294. 

Hirschfeld,  107. 

Hoar,  C.,  317. 

Holmes,  124,  307,  309. 

Howse,  256. 

Hiieter,   37,    69,    1S6,    213,   245, 

255»  296,  392. 
Human  morphology,  160,  351. 
Hutchinson,  J.,  299. 
Hyrtl,  376. 

Infantile  spinal  paralysis, 
422  ;  symptoms,  422  ;  treat- 
ment, 422  ;  instrument  for 
paralysis  of  lower  limb,  426. 

Israel,  144. 

Jacket,  plaster  of  Paris,  142. 
Jackson,  Dr.,  89,  179,  271. 
Jacobson,  385. 
Jenner,  79. 
Jerk  finger,  373. 
Jews,  227. 

Kassowitz,  19. 
Knees,  weak,  2S3. 
Koenig,  257,  356. 

Kyphosis  (see  cyphosis). 

Labbe,  371,  372. 

Lachaise,  69. 

Lacour,  198. 

Lamballe,  Joubert  de,  262. 

Lancet,  133,  145,  271. 

Lanceraux,  358. 

Langenbeck,  252,  262,  414. 


45^ 


INDEX. 


Langton,  271. 

Lannelongue,  147,  148,  151,219, 
240,  243,  245. 

Lebelleguie,  116. 

Lemercier,  261. 

Ling,  67,  68. 

Linhart,  240. 

Lisfranc,  377. 

Little,  150,  170,  223,  234,  261, 
263,  271,  367. 

Little,  S.,  414. 

Lipscombe,  299. 

Lonsdale,  147,  148. 

Lordosis,  118;  causes,  119;  from 
paralysis  of  abdominal  muscles, 
120;  pelvic  extenders,  120; 
upper  dorsal,  119;  definition, 
118;  treatment,  123  ;  varieties, 
118. 

Lorenz,  186,  187,  188. 

Louvrier,  282. 

Lower  limb,  deformities  of,  146, 
280,  292 ;  paralytic  displace- 
ments of,  430. 

Lund,  62,  170,  217. 

Macewen,  235,  238,    255,  260, 

263,  267,  290. 
Madelung,  O.  W.,  360,365,  366. 
Maisonneuve,  262. 
Malgaigne,    36,    149,    262,    313, 

328. 
Marchand,  249. 
Marsh,  Mr.  H.,  128. 
Martino,  442. 
Maunder,  263,  409. 
Mayo,  35. 
McEwen,  261,  262,  264,  265,  266, 

267,  268,  269,  270. 
McGill,  174,  271. 
Meckel,  1 5 1.  . 
Mellet,  235. 
Menzel,  374,  376,  385. 
Meusel,  173. 
Meyer,  Herman  Von,   187,  261, 

262. 
Mikulicz's  skoliosometer,  25,  26, 

27,    28,    233,    238,    240,    242, 

248. 
Minerva,  100,  101. 
Morgan,  Campbell  de,  98. 


Mosetig,  11. 

Muscular  contractions, -232  ;  spas- 
tic of  flexors  and  adductors,  &c. , 

433  ;  causes,  433  ;  tenotomy  of 
adductors  and  hamstrings,  43  5 ; 
instrument  for  use  after,  435  ; 
of  flexors  of  wrist  and  fingers, 

434  J  treatment,  434. 

Naegele,  304. 

Nelaton,  376. 

Nervous  deformities,  421. 

Nicoladoni,  39. 

Norton,  343.  _ 

Nose,  deformity  of,  437  ;  appar- 
atus for  straightening  of,  438  ; 
depressed  bridge  before  and 
after  operation,  439 ;  operation, 

439- 
Notta,  374,  376. 
Nunn,  321. 
Nyrop,  115,  116,  117,  201. 

Ogston,  174,  202,  235,  260,  263, 
264,  265,  271,  274. 

Oilier,  235,  236,  261,  281. 

Ormsby,  180. 

Orthopaedic,  definition  of,  I  ; 
gymnastics,  64  ;  history  of,  2  ; 
therapeutics,  general  remarks 
on,  7. 

Osteectomy,  279. 

Osteoclasy,  282  ;  severe  double 
genu  valgum  after  diaphysial 
osteotomy,  282  ;  weak  knees, 
283. 

Osteotomy,  260  ;  operative  plans 
for  genu  valgum  and  varum, 
260  :  where  bone  is  divided  in, 
265  ;  Diaphysial,  278  ;  Epi- 
physial chondrotomy,  281  ;  in- 
ternal condylotomy,  272 ;  supra- 
condylar, 265  ;  extreme  genu 
valgum  before  and  after  condy- 
lotomy, 274,  277  ;  graduated 
osteotome,  267  ;  lines  of  bony 
section,  268  ;  table  of,  280. 

Owen,  240. 

Paget,  Sir  J.,  5,  7,  385. 
Palmar     fascia,    contraction     of 


INDEX. 


457 


353  ;  causes,  353  ;  definition, 
353  ;  diagnosis,  362  ;  open 
division,  363  ;  pathology,  355  ; 
contraction,  dissection,  &c,  of 
fingers,  355,  357.  359,  361  5 
relapse  of  contraction,  370  ; 
subcutaneous  operations  of, 
367  ;  instrument  to  be  worn 
after  division  of,  369 ;  symp- 
toms, 354  ;  treatment,  362. 

Pancoast,  210,  262,  263. 

Paralysis,  Infantile  spinal,  422  ; 
symptoms,      422 ;      treatment, 

426  ;  instrument  for,  426. 
Paralytic    deformities    of    upper 

limb,  246  ;  causes,  429  ;  del- 
toid, 426  ;  diagnosis,  429  ;  ser- 
ratus  magnus,  427  ;  character- 
istic    deformity    at     shoulder, 

427  ;  treatment,  430  ;  displace- 
ments of  the  lower  limb,  430  ; 
backward  dislocation  of  knee, 

43i- 
Parker,  150,  264. 

Parrot,  12. 
Partridge,  356. 

Pen  for  writers'  paralysis,  351. 
Phelps,  Dr.,  176. 
Pigeon-breast,  78;  toe,  311,  3I7- 
Pirogoff,  177. 
Pitha,  Von,  376. 
Plantaris,  225  (see  Cavus). 
Planus  (pes),  227  ;  causes,  227  ; 
definition,  227  ;  diagnosis,  229  ; 
impression   of    fiat- foot,    228  ; 
symptoms  and  external  appear- 
ances,   229  ;    synonyms,    227  ; 
treatment,  229. 
Poinsot,  170,  171,  172. 
Polydactylism,  323,  337. 
Post,  363,  366. 
Pravaz,  66,  308. 
Prophylaxis  of  deformities,  6. 

Rabagliati,  271. 

Rauchfuss,  140. 

Reclus,  144- 

Reismann,  187. 

Revher,  385. 

Richet,  353,  363,  304-  372. 

Rickets,   10;  causes  of,    11  ;  de- 


finition, 10  ;  parts  chiefly  af- 
fected, 12  ;  deformity  of  fore- 
arm, 13  ;  pathology,  15  ;  severe 
deformity  of  lower  limbs,  16  ; 
prognosis,  17  ;  lateral  curva- 
ture, 18  ;  symptoms  and  diag- 
nosis, 14;  synonyms,  10; 
treatment,  18  ;  varieties,  10. 

Ricord,  353. 

Riecke,  262. 

Rignetta,  198. 

Rivington,  420. 

Rizzoli,  282,  417. 

Robert,  97.    • 

Robin,  151,  282,  283. 

Rodgers,  K.,  262. 

Roliff,  12. 

Roser,  294,  377,  3S0. 

Rudolphi,  150. 

Rupprecht,  172. 

Rydygier,  173,  174- 

Saixt-Hilaire,  151. 

Samuel,  257. 

Sandals,  315,  3 1 9. 

Sanson,  356. 

Santi,  243,  257. 

Sayre,    26,   65,    72,   73,    75,    76, 

115,  124,    126,   127,    142,    143, 

155,  263,  294,  413,  433- 
Scarpa,    151,    164,  165,  166,  167, 

168,  178,  215. 
Schede,  261,  263. 
Schramm,  29,  75,  116,  283,  332. 
Scoliosis,  30. 
Scoutetton,  11. 
Severin,  124. 
Shaffer,  Dr.,  5,  132,  135. 
Shattock,  150. 
Shaw,  115. 
Silcock,  150. 
Skoliosometer,  Mikulicz's,  25,  26, 

27,  28. 
Smith,  Dr.  E.,  298. 
Smith,  X.,  362. 
Smith,  T.,  420. 
Snap  finger,  373  (see  Finger). 
Solly,  in,  70. 
Southam,  354 
Spinal   paralysis,     infantile,    422 

(see  Paralysis). 


45§ 


INDEX. 


Spine  and  trunk,  deformities  of, 
21 ;  essentials  of  spinal  anat- 
omy, 21  ;  examination  of  spine, 
23  ;  normal  posterior  aspect  of 
female  trunk,  23 ;  vertebra  from 
behind,  24. 

Spine,  curvatures  of,  30 ;  abdom- 
inal viscera,  59  ;  caries  of,  124 
(see  Caries)  ;  causes,  32  ;  lateral 
curvature  due  to  inequality  and 
altered  axis  of  support,  32 ; 
unequal  weight  of  two  sides  of 
trunk,  33  ;  course  and  prog- 
nosis, 60 ;  how  a  curve  can  be 
produced  and  an  existing  one 
corrected,  63  ;  definition,  30  ; 
diagnosis,  39  ;  defective  devel- 
opment of  left  scapula,  40 ; 
congenital  scoliosis,  42  ;  elec- 
tricity, 69 ;  forcible  rectification 
under  anaesthesia,  76 ;  fre- 
quency, 30  ;  gymnastics,  64  ; 
apparatus  for  extension  and 
counter-extension,  64 ;  mas- 
sage, 69  ;  mechanical  appara- 
tus, 69  ;  myotomy,  76  ;  ortho- 
paedic gymnastics,  64 ;  action 
of  lateral  curvature  cradle,  66  ; 
osseous  theories,  37  ;  pathogen- 
esis, 34  ;  left  pleuritic  lateral 
curvature,  35,  36  ;  pathological 
anatomy,  5 1  ;  paralytic  general 
kypho-scoliosis,  53  ;  thorax 
from  a  case  of  scoliosis,  55  ; 
front  and  back  views  of  severe 
case  of  dorso-lumbar  lateral, 
58  ;  pelvic  viscera,  60  ;  plaster 
jacket,  72  ;  corrector,  72  ;  sup- 
port for  right  dorsal  and  left 
lumbar  lateral,  74  ;  rest,  62  ; 
summary  of  Treatment,  76  ; 
supports  and  corsets,  70  ; 
symptoms,  43  ;  deviation  of 
anterior  mid-line  of  body,  48  ; 
left  dorso-lumbar  curvature, 
46 ;  right  lower  dorsal  and  left 
lumbar  curvature,  51  ;  syno- 
nyms, 30  ;  tenotomy,  76  ; 
thoracic  viscera,  56  ;  treat- 
ment, 61  ;  varieties,  30  ;  pro- 
duction of  lateral  curvature  by 


inequality    of    length    of     the 

limbs,  31. 
Spondylitis,  124. 
Spring  finger,   373   {see  Finger)  ; 

corrector,  115. 
Stokes,  180. 

Stromeyer,  186,  234,  367. 
Suspensory  cradle,  140. 
Swan,  180. 
Swimming,  66. 
Syme,  177. 
Syndactylism,  323,  339. 

Talipes,  146  {see  Club-foot) ;  cal- 
caneus, 218. 

Tamplin,  no,  147,  148,  254,353. 

Tarsotomy,  170. 

Taviner,  71. 

Taylor,  136,  143,  265. 

Teissier,  385. 

Tenotomes,  163. 

Terrillon,  249. 

Therapeutics,  orthopaedic,  7. 

Thomas,  437. 

Thorax,  deformities  of,  78 ; 
pathogenesis,  78;  pigeon  breast, 
78  ;  prognosis,    79  ;  symptoms, 

78  ;  synonyms,   78  ;  treatment, 

79  ;  varieties  and  causes,  78. 
Thorens,  151. 

Tibia  and  fibula,  curved,  289 ; 
treatment,  289  ;  severe  case  be- 
fore and  after  osteotomy,  290. 

Tillaux,  236,  248,   256,  257,  258, 

.259,  37 1- 

Tillman,  299. 

Toes,  deformities  of,  31 1  ;  causes, 
311  ;  varieties,  311  ;  extension 
of     entire,      319;      treatment, 

319  ;  extension  of  first 
phalanx  and  flexion  of  others, 

320  ;  hammer,  320  ;  pathology, 

321  ;  feet  of  a  patient  the  sub- 
ject of  congenital  hammer,  321 ; 
symptoms,  320 ;  treatment, 
321  ;  infant  with  congenital 
occipital  encephalocele,  322, 
324  ;  bunions,  corns  and  gang- 
lions, 324 ;  deficient  or  excess- 
ive development  of,  323  ;  ill- 
turned,     324 ;     equinus-valgus 


INDEX. 


459 


and  deformed  toes,  &c,  324  ; 
causes,   324 ;    treatment,    325  ; 
syndactylism,     323 ;     defective 
and  webbing  of,    323  ;   flexion 
of,  318;  treatment,  318,;  sandal 
with  spring  and  one  with  loops, 
319 ;    transverse    displacement 
of,  312;    Hallux  valgus,   312 
causes,  312  ;  transverse  devia 
tion  of,  313;  pathology,   314 
apparatus  to  correct  great  toe 
315  ;    sandal   with   cog-wheel 
315;    symptoms,    312;    treat 
ment,  316  ;  Hallux  varus,  317 
causes,  317  ;    symptoms,   317 
treatment,    317  ;    vertical   dis 
placement  of,  317;  causes,  317 
symptoms,  318;  varieties,  317 
Torticollis,    83    {see    Wry-neck) 
definition,  83  ;  due  to  contrac 
tion     of    sterno-mastoid,    86 
muscular,    showing     curve     of 
spine,  &c. ,  88  ;    rotatory,  90 
spasmodic  or  intermittent,  89 
synonyms,  83  ;  traumatic,  84 
cicatricial,  85  ;   spastic  muscu 
lar,  86  ;   varieties   and  causes 
83  ;   congenital   muscular,   84 
osseous  and  articular,  102  ;  ap- 
paratus  for   elastic    control   of 
affected   muscle,    102  ;   causes, 
102  ;  extreme  deformity,   103  ; 
diagnosis,  104 :  prognosis,  105  ; 
symptoms,      103  ;      treatment, 
105  ;   apparatus  for  fixing  and 
extending  in,  105. 
Treves,  144,  145- 

Universal  talipes  shoe,  165. 

Unreduced      dislocations,      148  ; 

treatment,  418  ;  complications, 

4X9- 
Upper  limb,  deformities  of.  281, 
326  ;   paralytic  deformities   of, 
429. 

Valgus  ankle,  196  ;  symptoms, 
196  ;  treatment.  196  ;  congen- 
ital, 197  ;  morbid  anatomy, 
198  ;  double  valgus,  198  ;  Og- 
ston's   operation,    202  ;    symp- 


toms, 199  ;  tenotomy,  201  ; 
treatment,  199  ;  Nyrop's  valgus 
boot,  201. 
Valgus  (pes)  acquisitus,  184 ; 
causes  and  varieties,  184  ;  de- 
grees, 185  ;  definition,  184 ; 
diagnosis,  195  ;  mode  of  pro- 
duction, 194  ;  paralytic,  189  ; 
diagram  of  bad,  from  above, 
190 ;      pathological     anatomy, 

185  ;  external  aspect  of  normal 
and  severe   valgoid   foot   arch, 

186  ;  skeleton  of  converse  sole, 
188  ;  inner  view  of  bones  of 
severe  valgus,  188;  severe  right 
valgus,  189 ;  prognosis,  196  ; 
symptoms  and  external  appear- 
ances, 190 ;  impression  of  a 
normal  sole,  191. 

Vallette,  298. 

Variot,  358. 

Varus,  untreated  and  relapsed, 
168  ;  equino-varus-toes  curled 
up,  169;  tarsotomy,  170;  dia- 
gram of  bony  section  for  severe 
equino-varus,  171  ;  cuneiform, 
171  ;  pes,  177  ;  summary  of 
treatment,  178. 

Verneuil,  234,  235,  236,  294,  297, 

431*  437- 
Verrier,  304. 
Vertebra,  diagram  of,  24  ;  torsion 

of,  28. 
Vertebral  caries,  124  [see  Spinal). 
Virchow,  17. 
Vogt,  71,  136,  374. 
Volkmann,    70,    187,    241,    263, 

282,  294,  388>  39°,  4*3- 

Walsham,  441. 

Wasserfuhr,  261. 

Watson,  411. 

Weber,  107. 

Weber,  Otto,  171. 

Weinlechner,  II. 

Williams,  Mr.  R.,  3. 

Wolff,  63. 

Wood,  J.,  3»  19.  445- 

Writers'  palsy,  351. 

Writing  positions..  5,  6,  8. 

Wry-neck,    83    {see  Torticollis)  ; 


460 


INDEX. 


age,  sex,  and  side  of  disease, 
92 ;  diagnosis,  94  ;  division 
and  stretching  of  spinal  acces- 
sory, 99  ;  collar  for,  99  ;  in- 
struments, 100  ;  with  ball  and 
racket-joint,  100  ;  key  and 
racket  joint,  100 ;  paralytic, 
90  ;  pathology,  93  ;  produced 
by  other  cervical  muscles,  90  ; 


from     nervous     diseases,     91  ; 
prognosis,  95  ;  spasmodic,  98  ; 
symptoms,   92  ;  tenotomy,  97  ; 
treatment,  95. 
Wursburg,  262. 

Zander,  67. 
Zeller,  342. 


CATALOGUE  No.  7. 


A  CATALOGUE 


OF 


Books  for  Students; 

INCLUDING   A    FULL    LIST    OF 

The  ? Quiz-Compends ? 

AND   MANY    OF 

THE   MOST   PROMINENT 

Students'  Manuals  and  Text-Books 

PUBLISHED   BY 

P.  BLAKISTON,  SON  &  CO., 

Medical  Booksellers,  Importers  and  Publishers, 
No.  1012  WALNUT  STREET, 

PHILADELPHIA. 


***  For  sale  by  all  Booksellers,  or  any  book  will  be  sent  by  mail, 
postpaid,  upon  receipt  of  price.  Catalogues  of  books  on  all  branches 
of  Medicine,  Dentistry,  Pharmacy,  etc.,  supplied  upon  application. 


THE  PQUIZ-COMPENDS? 

A  NEW  SERIES  OF  COMPENDS  FOR  STUDENTS. 

For  Use  in  the  Quiz  Class  and  when 

Preparing  for  Examinations. 

Price  of  Each,  Bound  in  Cloth,  $1.00    Interleaved,  $1.25. 


Based  on  the  most  popular  text-books,  and  on  the  lec- 
tures of  prominent  professors,  they  form  a  most  complete 
set  of  manuals,  containing  information  nowhere  else 
collected  in  such  a  condensed,  practical  shape.  The 
authors  have  had  large  experience  as  quiz-masters  and 
attaches  of  colleges,  with  exceptional  opportunities  for 
noting  the  most  recent  advances  and  methods.  The 
arrangement  of  the  subjects,  illustrations,  types,  etc.,  are 
all  of  the  most  improved  form,  and  the  size  of  the  books 
is  such  that  they  may  be  easily  carried  in  the  pocket. 

No.  1.    ANATOMY.    (Illustrated.) 

THIRD  REVISED  EDITION. 
A  Compend  of  Human  Anatomy.     By  Samuel  O.  L. 
Potter,  m.A.,  m.d.,  U.  S.  Army.  With  63  Illustrations. 

"  The  work  is  reliable  and  complete,  and  just  what  the  student 
needs  in  reviewing  the  subject  for  his  examinations." — The  Physi- 
cian and  Surgeon1  s  Investigator ,  Buffalo,  N.  Y. 

"  To  those  desiring  to  post  themselves  hurriedly  for  examination, 
this  little  book  will  be  useful  in  refreshing  the  memory." — New 
Orleans  Medical  and  Surgical  yournal. 

"The  arrangement  is  well  calculated  to  facilitate  accurate  memo- 
rizing, and  the  illustrations  are  clear  and  good." — North  Carolina 
Medical  Journal. 

Nos.  2  and  3.    PRACTICE. 

A  Compend  of   the   Practice  of    Medicine,  especially 
adapted  to  the  use  of  Students.  By  Dan'l  E.  Hughes, 
M.D.,  Demonstrator  of  Clinical  Medicine  in  Jefferson 
Medical  College,  Philadelphia.     In  two  parts. 
Part  I. — Continued,  Eruptive,  and  Periodical  Fevers, 
Diseases  of  the  Stomach,  Intestines,  Peritoneum,  Biliary 
Passages,  Liver,  Kidneys,  etc.,  and  General  Diseases,  etc. 
Part  II. — Diseases  of  the  Respiratory  System,  Circu- 
latory System,  and  Nervous  System ;   Diseases   of  the 
Blood,  etc. 

*%*  These  little  books  can  be  regarded  as  a  full  set  of 
notes  upon  the   Practice  of    Medicine,   containing   the 
Price  of  each  Book,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


THE  ?  QUIZ-COMPENDS  ?. 


Synonyms,  Definitions,  Causes,  Symptoms,  Prognosis, 
Diagnosis,  Treatment,  etc.,  of  each  disease,  and  includ- 
ing a  number  of  new  prescriptions.  They  have  been 
compiled  from  the  lectures  of  prominent  Professors,  and 
reference  has  been  made  to  the  latest  writings  of  Pro- 
fessors Flint,  Da  Costa,  Reynolds,  Bartholow, 
Roberts  and  others. 

"  It  is  brief  and  concise,  and  at  the  same  time  possesses  an  accu- 
racy not  generally  found  in  compends." — yas.  M.  French,  M.D., 
Ass't  to  the  Prof,  of  Practice,  Medical  College  of  Ohio,  Cincinnati. 

"The  book  seems  very  concise,  yet  very  comprehensive.  .  .  . 
An  unusually  superior  book."— Dr.  E.  T.  Bruen,  Demonstrator 
of  Clinical  Medicine ,  University  of  Pennsylvania. 

"  I  have  used  it  considerably  in  connection  with  my  branches  in 
the  Quiz-class  of  the  University  of  La."— y.  H.  Bemiss,  New 
Orleans. 

"  Dr.  Hughes  has  prepared  a  very  useful  little  book,  and  I  shall 
take  pleasure  in  advising  my  class  to  use  it." — Dr.  George  W. 
Hall,  Professor  of  Practice,  St.  Louis  College  of  Physicians  and 
Surgeons. 

No.  4.    PHYSIOLOGY.     Second  Ed. 

A  Compend  of  Human  Physiology,  adapted  to  the  use 
of  Students.     By  Albert    P.  Brubaker,  m.d.,  De- 
monstrator of  Physiology  in  Jefferson  Medical  College, 
Philadelphia.     Second  Ed.     Enlarged  and  Revised. 
"  Dr.  Brubaker  deserves  the  hearty  thanks  of  medical  students 
for  his  Compend  of  Physiology.    He  has  arranged  the  fundamental 
and  practical  principles  of  the  science  in  a  peculiarly  inviting  and 
accessible  manner.     I  have  already  introduced   the  work  to  my 
class." — Maurice  N.  Miller,  M.D.,  Instructor  in  Practical  His- 
tology, formerly  Demonstrator  of  Physiology,  University  City  of 
New  York. 

"'Quiz-Compend'  No.  4  is  fully  up  to  the  high  standard  estab- 
lished by  its  predecessors  of  the  same  series." — Medical  Bulletin, 
Philadelphia. 

"I  can  recommend  it  as  a  valuable  aid  to  the  student." — C.  N. 
Ellinwood,  M.D.,  Professor  of  Physiology,   Cooper  Medical  Col- 
lege, San  Francisco. 
"  This  is  a  well  written  little  book." — London  Lancet. 

No.  5.     OBSTETRICS. 

A  Compend  of  Obstetrics.  For  Physicians  and  Students. 

By  Henry  G.  Landis,  m.d.,  Professor  of  Obstetrics 

and  Diseases  of  Women,  in  Starling  Medical  College, 

Columbus.     22  Illustrations. 

"  We  have  no  doubt  that  many  students  will  find  in  it  a  most 
valuable  aid  in  preparing  for  examination." — The  American  your- 
nal  of  Obstetrics. 

"  It  is  complete,  accurate  and  scientific.     The  very  best  book  ot 
its  kind  I  have  seen."— y.  S.  Knox,  M.D.,  Lecturer  on  Obstetrics, 
Rush  Medical  College,  Chicago. 
Price  of  each  Book,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


THE  ?  QUIZ-COMPENDS  ?. 


"  I  have  been  teaching  in  this  department  for  many  years,  and  am 
free  to  say  that  this  will  be  the  best  assistant  I  ever  had.  It  is  ac- 
curate and  comprehensive,  but  brief  and  pointed." — Prof.  P.  D. 
Yost,  St.  Louis. 

No.  6.    MATERIA  MEDIOA.    Revised  Ed. 

A  Compend  on  Materia  Medica  and  Therapeutics,  with 
especial  reference  to  the  Physiological  Actions  of 
Drugs.  For  the  use  of  Medical,  Dental,  and  Pharma- 
ceutical Students  and  Practitioners.  Based  on  the  New- 
Revision  (Sixth)  of  the  U.  S.  Pharmacopoeia,  and  in- 
cluding many  unofficinal  remedies.  By  Samuel  O. 
L.  Potter,  M.A.,  M.D.,  U.  S.  Army. 

"  I  have  examined  the  little  volume  carefully,  and  find  it  just 
such  a  book  as  I  require  in  my  private  Quiz,  and  shall  certainly  re- 
commend it  to  my  classes.  Your  Compends  are  all  popular  here  in 
Washington." — John  E.  Brackett,  M.D.,  Professor  of  Materia 
Medica  and  Therapeutics ,  Howard  Medical  College,  Washington. 

"  Part  of  a  series  of  small  but  valuable  text-books.  .  .  .  While 
the  work  is,  owing  to  its  therapeutic  contents,  more  useful  to  the 
medical  student,  the  pharmaceutical  student  may  derive  much  use- 
ful information  from  it." — N.  Y.  Pharmaceutical  Record. 

No.  7.    CHEMISTRY.    Revised  Ed. 

A  Compend  of  Chemistry.     By  G.  Mason  Ward,  m.d., 
Demonstrator  of  Chemistry  in  Jefferson  Medical  Col- 
lege, Philadelphia.    Including  Table  of  Elements  and 
various  Analytical  Tables. 
"  Brief,  but  excellent.  ...  It  will  doubtless  prove  an  admirable 

aid  to  the  student,  by  fixing  these  facts  in  his  memory.    It  is  worthy 

the  study  of  both  medical  and  pharmaceutical   students   in   this 

branch." — Pharmaceutical  Record,  New  York. 

No.  8.    VISCERAL  ANATOMY. 

A  Compend  of  Visceral  Anatomy.     By  Samuel  O.  L. 

Potter,  m.A.,  m.d.,  U.  S.  Army.    With  40  Illustrations. 

*#*  This  is  the  only  Compend  that  contains  full  descriptions  of  the 
viscera,  and  will,  together  with  No.  i  of  this  series,  form  the  only 
complete  Compend  of  Anatomy  published. 

No.  9.     SURGERY.     Second  Edition. 

A  Compend  of  Surgery;  including  Fractures,  Wounds, 
Dislocations,  Sprains,  Amputations  and  other  opera- 
tions, Inflammation,  Suppuration,  Ulcers,  Syphilis, 
Tumors,  Shock,  etc.  Diseases  of  the  Spine,  Ear,  Eye, 
Bladder,  Testicles,  Anus,  and  other  Surgical  Diseases. 
By  Orville  Horwitz,  A.m.,  m.d.,  with  62  Illustra- 
tions.    Second  Edition.     Enlarged  and  Revised. 

Price  of  Each  Book,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


THE  ?QUIZ-COMPENDS!. 


No.  10.     ORGANIC  CHEMISTRY. 

JUST  PUBLISHED. 
A  Compend  of  Organic  Chemistry,  including  Medical 
Chemistry,  Urine  Analysis,  and  the  Analysis  of  Water 
and  Food,  etc.  By  Henry  Lbffmann,  m.d.,  Pro- 
fessor of  Clinical  Chemistry  and  Hygiene  in  the  Phila- 
delphia Polyclinic ;  Professor  of  Chemistry,  Penn- 
sylvania College  of  Dental  Surgery  ;  Member  of  the 
N.  Y.  Medico-Legal  Society.  Cloth.     Si.oo. 

Interleaved,  for  the  addition  of  Notes,  Si. 25. 

Nature  of  Organic  Bodies.  Transformations  under  various  con- 
ditions. Organic  Synthesis.  Homologous  and  Isomeric  Bodies. 
Empirical  and  Rational  formulae.  Classification  of  Organic  Bodies. 
Hydrocarbon.  Derivatives  of  Hydrocarbons,  Alcohols  and  Ethers. 
Be'nzenes  and  Turpenes.  Fat  Acids,  Oils  and  Fats,  Sugars,  Gluco- 
sides.  Cyanogen  Compounds.  Amines  and  Amides.  Alkaloids. 
Ptomaine's.  Animal  Chemistry.  Nutrition  and  Assimilation. 
Food,  Water  and  Air.     Urinary  Analysis.     Index. 

The  Essentials  of  Pathology. 

BY  D.  TOD  GILLIAM,  M.D., 

Professor  of  Physiology  in  Starling  Medical  College,  Columbus,  O. 

With  47  Illustrations.    12mo.    Cloth.    Price  $2.00. 

*^t  The  object  of  this  book  is  to  unfold  to  the  beginner  the  funda- 
mentals of  pathology  in  a  plain,  practical  way,  and  by  bringing  them 
within  easy  comprehension  to  increase  his  interest  in  the  study  ot 
the  subject.  Though  it  will  not  altogether  supplant  larger  works, 
it  will  be  found  to  impart  clear-cut  conceptions  of  the  generally 
accepted  doctrines  of  the  day,  and  to  prevent  confusion  in  the  mind 
of  the  student. 

A  POCKET-BOOK  OF 

PHYSICAL    DIAGNOSIS 

OF   THE 

Diseases  of  the  Heart  and  Lungs. 

A   MANUAL  FOR   STUDENTS  AND   PHYSICIANS. 

BY  DR.  EDWARD  T.  BRUEN, 
Demonstrator  of  Clinical  Medicine  in  the  University  of  Pennsyl- 
vania, Assistant  Physician  to  the  University  Hospital,  etc. 

Second  Edition.  Revised.    With  new  Illustrations.    12mo.    $1.50. 

*^*  The  subject  is  treated  in  a  plain,  practical  manner,  avoiding 
questions  of  historical  or  theoretical  interest,  and  without  laying 
special  claim  to  originality  of  matter,  the  author  has  made  a  book 
that  presents  the  somewhat  difficult  points  of  Physical  Diagnosis 
clearly  and  distinctly. 


STUDENTS'  MANUALS. 


TYSON,  ON  THE  URINE.  A  Practical  Guide  to 
the  Examination  of  Urine.  For  Physicians  and  Stu- 
dents. By  James  Tyson,  m.d.,  Professor  of  Path- 
ology and  Morbid  Anatomy,  University  of  Pennsylva- 
nia. With  Colored  Plates  and  Wood  Engravings. 
Fourth  Edition.  i2mo,  cloth,  $1.50 

HEATH'S  MINOR  SURGERY.  A  Manual  of 
Minor  Surgery  and  Bandaging.  By  Christopher 
Heath,  m.d.,  Surgeon  to  University  College  Hospital, 
London.     6th  Edition.     115  111.     1 2mo,  cloth,  $2.00 

MACNAMARA,  ON  THE  EYE.  A  Manual  for 
Students  and  Physicians.  4  Colored  Plates  and  65 
Wood  Engravings.     Demi  8vo.  Cloth,  $4.00. 

VIRCHOW'S  POST-MORTEMS.  Post-Mortem 
Examinations.  A  Description  and  Explanation  of  the 
Methods  of  Performing  them.  By  Prof.  Rudolph 
Virchow,  of  Berlin.  Translated  by  Dr.  T.  B.  Smith. 
2d  Ed.     4  Lithographic  Plates.         i2mo,  cloth,  #1.25 

DULLES'  ACCIDENTS  AND  EMERGEN- 
CIES. What  To  Do  First  in  Accidents  and  Emer- 
gencies. A  Manual  Explaining  the  Treatment  of 
Surgical  and  other  Accidents,  Poisoning,  etc.  By 
Charles  W.  Dulles,  m.d.,  Surgeon  Out-door  De- 
partment, Presbyterian  Hospital,  Philadelphia.  Col- 
ored Plate  and  other  Illustrations.        32mo,  cloth,  .75 

BEALE,  ON  SLIGHT  AILMENTS.  Their  Na- 
ture and  Treatment.  By  Lionel  S.  Beale,  m.d., 
f.r.s.  Second  Edition.  Revised,  Enlarged  and  Illus- 
trated.    283  pages.     8vo. 

Paper  covers,  75  cents;  cloth,  $1.25 

ALLINGHAM,  ON  THE  RECTUM.  Fistulse, 
Hemorrhoids,  Painful  Ulcer,  Stricture,  Prolapsus,  and 
other  Diseases  of  the  Rectum ;  Their  Diagnosis  and 
Treatment.  By  Wm.  Allingham,  m.d.  Fourth  Re- 
vised and  Enlarged  Edition.     Illustrated.     8vo. 

Paper  covers,  75  cents;  cloth,  $1.25 

AITKEN,  THE  SCIENCE  AND  PRACTICE 
OF  MEDICINE.  A  New  (Seventh)  Edition.  2 
Vols.     8vo.  Cloth,  $12.00;  Leather,  $14.00. 


STUDENTS'  MANUALS  AND  LEXICONS. 


MARSHALL  AND  SMITH,  ON  THE  URINE. 

The  Chemical  Analysis  of  the  Urine.  By  John  Mar- 
shall, M.D.,  Chemical  Laboratory,  University  of  Penn- 
sylvania, and  Prof.  E.  F.  Smith.  Illus.  Cloth,  $i  oo 

MEARS'  PRACTICAL  SURGERY.  Surgical 
Dressings,  Bandaging,  Ligation,  Amputation,  etc.  By 
T.  Ewing  Mears,  m.d.,  Demonstrator  of  Surgery  in 
Jefferson  Med.  College.  227  Illus.    2d  Ed.     In  Press. 

KIRKE'S  PHYSIOLOGY.  A  Handbook  for  Stu- 
dents. Eleventh  Edition,  1884.  466  Illustrations. 
Demi  8vo.  clotn>  #5-°° 

TYSON,  ON  THE  CELL  DOCTRINE;  its  His- 
tory and  Present  State.  By  Prof.  James  Tyson,  m.d. 
Second  Edition.     Illustrated.  i2mo,  cloth,  $2.00 

MEADOWS'  MIDWIFERY.  A  Manual  for  Stu- 
dents. By  Alfred  Meadows,  m.d.  From  Fourth 
London  Edition.     145  Illustrations.    8vo,  cloth,  $2.00 

WYTHE'S  DOSE  AND  SYMPTOM  BOOK. 
Containing  the  Doses  and  Uses  of  all  the  principal 
Articles  of  the  Materia  Medica,  etc.  Eleventh  Edi- 
tion.        32mo,  cloth,  $1.00;  pocket-book  style,  #1.25 

PHYSICIAN'S  PRESCRIPTION  BOOK.  Con- 
taining Lists  of  Terms,  Phrases,  Contractions  and 
Abbreviations  used  in  Prescriptions,  Explanatory  Notes, 
Grammatical  Construction  of  Prescriptions,  etc.,  etc. 
By  Prof.  Jonathan  Pereira,  m.d.  Sixteenth  Edi- 
tion.        32010,  cloth,  #1.00;  pocket-book  style,  #1.25 

POCKET  LEXICONS. 

CLEAVELAND'S  POCKET  MEDICAL  LEXI- 
CON. A  Medical  Lexicon,  containing  correct  Pro- 
nunciation and  Definition  of  Terms  used  in  Medi- 
cine and  the  Collateral  Sciences.  Thirtieth  Edition. 
Very  small  pocket  size.     Red  Edges. 

Cloth,  75  cents;  pocket-book  style,  $1.00 

LONGLEY'S    POCKET    DICTIONARY.      The 

Student's  Medical  Lexicon,  giving  Definition  and  Pro- 
nunciation of  all  Terms  used  in  Medicine,  with  an 
Appendix  giving  Poisons  and  Their  Antidotes,  Abbre- 
viations used  in  Prescriptions,  Metric  Scale  of  Doses, 
etc.  24mo,  cloth,  $1.00;  pocket-book  style,  $1.25 


ROBERTS'  PRACTICE. 

Fifth  Edition. 

Recommended  as  a    Text-book  at   University  of  Pennsylvania , 
Long  Island  College  Hospital,  Yale  and  Harvard  Colleges, 
Bishop's  College,  Montreal,  University  of  Michigan,  and 
over  twenty  other  Medical  Schools. 
A  HANDBOOK  OF  THE  THEORY  AND   PRACTICE  OF 
MEDICINE.     By  Frederick   T.   Roberts,  m.d.,   m.r.c.p., 
Professor  of  Clinical  Medicine  and  Therapeutics  in  University- 
College  Hospital,  London.     Fifth  Edition.     Octavo. 

CLOTH,  $5.00;  LEATHER,  $6.00. 
*#*  This  new  edition  has  been  subjected  to  a  careful  revision. 
Many  chapters  have  been  rewritten.  Important  additions  have  been 
made  throughout,  and  new  illustrations  introduced. 

"A  clear,  yet  concise,  scientific  and  practical  work.  It  is  a  capi- 
tal compendium  of  the  classified  knowledge  of  the  subject." — Prof. 
J.  Adams  Allen,  Rush  Medical  College,  Chicago. 

"  I  have  become  thoroughly  convinced  of  its  great  value,  and 
have  cordially  recommended  it  to  my  class  in  Yale  College." — 
Prof.  David  P.  Smith. 

"  I  have  examined  it  with  some  care,  and  think  it  a  good  book, 
and  shall  take  pleasure  in  mentioning  it  among  the  works  which 
may  properly  be  put  in  the  hands  of  students." — A.  B.  Painter, 
Prof,  of  the  Practice  of  Medicine,   University  of  Michigan. 

"  It  is  unsurpassed  by  any  work  that  has  fallen  into  our  hands, 
as  a  compendium  for  students  preparing  for  examination.  It  is 
thoroughly  practical,  and  fully  up  to  the  times." — The  Clinic. 

By  Same  Author. 

ROBERTS'  NOTES  ON  MATERIA MEDICA 

AND    PHARMACY. 

Just  Ready.     12010.    Cloth  Price  $2.00. 

4@=*  A  new  Compend  for  Students. 

BIDDLE'S  MATERIA  MEDICA. 

Ninth  Revised  Edition. 

Recommended  as  a    Text-book  at    Yale    College,    University  of 

Michigan,   College  of  Physicians  and  Surgeons,  Baltimore, 

Baltimore  Medical  College,  Louisville  Medical  College, 

and  a  number  of  other  Colleges  throughout  the  U.  S. 

BIDDLE'S  MATERIA  MEDICA.  For  the  Use  of  Students  and 
Physicians.  By  the  late  Prof.  John  B.  Biddle,  m.d.,  Profes- 
sor of  Materia  Medica  in  Jefferson  Medical  College,  Philadelphia. 
The  Ninth  Edition,  thoroughly  revised,  and  in  many  parts  re- 
written, by  his  son,  Clement  Biddle,  m.d.,  Past  Assistant 
Surgeon,  U.  S.  Navy,  assisted  by  Henry  Morris,  m.d. 

CLOTH,  $4.00  ;  LEATHER,  $4.75. 
"I  shall  unhesitatingly  recommend  it  (the  9th  Edition)  to  my 

students  at  the  Bellevue  Hospital  Medical  College. — Prof. 

A.  A.  Smith,  New  York,  June,  1883. 
"  The  larger  works  usually  recommended  as  text-books  in  our 

medical  schools  are  too  voluminous  for  convenient  use.     This  work 

will  be  found  to  contain  in  a  condensed  form  all  that  is  most  valuable, 

and  will  supply  students  with  a  reliable  guide." — Chicago  Med.  Jl. 
***  This  Ninth  Edition  contains  all  the  additions  and  changes  in 

the  U.  S.  Pharmacopoeia,  Sixth  Revision. 


STANDARD  TEXT-BOOKS. 


BLOXAM'S  CHEMISTRY.  Inorganic  and  Organic,  with  Ex- 
periments.    Fifth  Edition.     Revised  and  Illustrated. 

8vo,  cloth,  $3.75;  leather,  $4.75 

CARPENTER  ON  THE  MICROSCOPE  and  Its  Revelations. 
Sixth  Edition,  Enlarged.  With  500  Illustrations  and  Colored 
Plates,  handsomely  printed.  Demi  8vo,  cloth,  $5.50 

FLOWER,  DIAGRAMS  OF  THE  NERVES  of  the  Human 
Body,  Origin,  Divisions,  Connections,  etc.  4*0,  cloth,  £3.50 

GLISAN'S  MODERN  MIDWIFERY.  A  Text-book.  129 
Illustrations.  8vo,  cloth,  $4.00;  leather,  $5.00 

HOLDEN'S  OSTEOLOGY.  A  Description  of  the  Bones,  with 
Colored  Delineations  of  the  Attachments  of  the  Muscles.  Sixth 
Edition.     61  Lithographic  Plates  and  many  Wood  Engravings. 

Royal  8vo,  cloth,  $6.00 

HEADLAND,  THE  ACTION  OF  MEDICINE  in  the  System. 
Ninth  American  Edition.  8vo,  cloth,  $3.00 

MANN'S  PSYCHOLOGICAL  MEDICINE  and  Allied  Ner- 
vous Diseases  ;  including  the  Medico-Legal  Aspects  of  Insanity. 
With  Illustrations.  8vo,  cloth,  $5.00;  leather,  £6. 00. 

MEIGS  AND  PEPPER  ON  CHILDREN.  A  Practical  Trea- 
tise on  Diseases  of  Children.     Seventh  Edition,  Revised. 

8vo,  cloth,  $6.00  ;  leather,  $7.00 

PARKES'  PRACTICAL  HYGIENE.  Sixth  Revised  and  En- 
larged Edition.     Illustrated.  8vo,  cloth,  $3.00 

RIGBY'S  OBSTETRIC  MEMORANDA.        32mo,  cloth,  .50 

SANDERSON  &  FOSTER'S  PHYSIOLOGICAL  LABOR- 
ATORY. A  Handbook  for  the  Laboratory.  Over  350  Illustra- 
tions. 8vo,  cloth,  $5.00;  leather,  $6.00 

WILSON'S  HUMAN  ANATOMY.  General  and  Special. 
Tenth  Edition.     26  Colored  Plates  and  424  Illustrations.        $6.00 

WYTHE'S  MICROSCOPIST^  A  Manual  of  Microscopy  and 
Compend  of  the  Microscopic  Sciences.  Fourth  Edition.  252 
Illustrations.  8vo,  cloth,  $3.00;  leather,  £4.00 

ACTON,  ON  THE  REPRODUCTIVE  ORGANS.  Their 
Functions,  Disorders  and  Treatment.    6th  Edition.    Cloth,  $2.00 

FOTHERGILL,  ON  THE  HEART.  Its  Diseases  and  their 
Treatment      Second  Edition.  8vo,  cloth,  $3.50 

HARLEY  ON  THE  LIVER.  Diagnosis  and  Treatment.  Col- 
ored Plates  and  other  Illustrations.   8vo,  cloth,  $5.00 ;  sheep,  $9.00 

HOLDEN'S  ANATOMY.        Fifth  Edition. 
Just  Ready. 

A  MANUAL  OF  THE  DISSECTION 

OP  THE  HUMAN  BODY. 

By  Luther  Holden,  M.S.,  Late  President  of  the  Royal  College 
of  Surgeons  of  England,  Consulting  Surgeon  to  St.  Bartholomew's 
Hospital.  Fifth  Edition;  edited  by  John  Langtox,  m.d.,  f.r.c.s., 
Surgeon  to,  and  Lecturer  on  Anatomy  at,  St.  Bartholomew's  Hos- 
pital; Member  of  the  Board  of  Examiners,  Royal  College  of  Sur- 
geons of  England;  with  208  fine  Wood  Engravings.  Octavo. 
886  pages.     Cloth,  $5.00  ;  Leather,  $6.00. 


REESE'S 
MEDICAL    JURISPRUDENCE 

AND  TOXICOLOGY. 

A  Text-book  of  Medical  Jurisprudence  and  Toxicology.  By 
John  J.  Reese,  m.  d.,  Professor  of  Medical  Jurisprudence  and 
Toxicology  in  the  Medical  and  Law  Departments  of  the  University 
of  Pennsylvania;  Vice-President  of  the  Medical  Jurisprudence  So- 
ciety of  Philadelphia  ;  Physician  to  St.  Joseph's  Hospital ;  Corres- 
ponding Member  of  the  New  York  Medico-legal  Society.  One 
Volume.     Demi  Octavo.    606  pages.    Cloth,  $4.00  ;  Leather,  $5.00. 

"  Professor  Reese  is  so  well  known  as  a  skilled  medical  jurist 
that  his  authorship  of  any  work  virtually  guarantees  the  thorough- 
ness and  practical  character  of  the  latter.  And  such  is  the  case  in 
the  book  before  us.  *  *  *  *  We  might  call  these  the 
essentials  for  the  study  of  medical  jurisprudence.  The  subject 
is  skeletonized,  condensed,  and  made  thoroughly  up  to  the  wants  ot 
the  general  medical  practitioner,  and  the  requirements  of  prose- 
cuting and  defending  attorneys.  If  any  section  deserves  more  dis- 
tinction than  any  other,  as  to  intrinsic  excellence,  it  is  that  on  toxi- 
cology. This  part  of  the  book  comprises  the  best  outline  of  the 
subject  in  a  given  space  that  can  be  found  anywhere.  As  a  whole, 
the  work  is  everything  it  promises  and  more,  and  considering  its 
size,  condensation,  and  practical  character,  it  is  by  far  the  most 
useful  one  for  ready  reference  that  we  have  met  with.  It  is  well 
printed  and  neatly  bound. — A7'.  Y.  Medical  Record,  Sept.  13th,  1884. 


RICHTER'S  CHEMISTRY, 

A  TEXT-BOOK  of  INORGANIC  CHEMISTRY  for  STUDENTS. 

By  PROF.  VICTOR  von  RICHTER, 

University  of  Breslau, 

Authorized  Translation  from  the  Third  German  Edition, 

By  EDGAR  F.  SMITH,  M.A.,  Ph.D., 

Professor  of  Chemistry  in  Wittenberg  College,  Springfield,  Ohio; 
formerly  in  the  Laboratories  of  the  University  of  Pennsyl- 
vania; Member  of  the  Chemical  Society  of  Berlin. 

12mo.  89  Wood-cuts  and  Coi.  Lithographic  Plate  of  Spectra.  $2.00 

In  the  chemical  text-books  of  the  present  day,  one  of  the  striking 
features  and  difficulties  we  have  to  contend  with  is  the  separate 
presentation  of  the  theories  and  facts  of  the  science.  These  are 
usually  taught  apart,  as  if  entirely  independent  of  each  other,  and 
those  experienced  in  teaching  the  subject  know  only  too  well  the 
trouble  encountered  in  attempting  to  get  the  student  properly  in- 
terested in  the  science  and  in  bringing  him  to  a  clear  comprehension 
of  the  same.  In  this  work  of  Prof,  von  Richter,  which  has  been 
received  abroad  with  such  hearty  welcome,  two  editions  having 
been  rapidly  disposed  of,  theory  and  fact  are  brought  close  together, 
and  their  intimate  relation  clearly  shown.  From  careful  observa- 
tion of  experiments  and  their  results,  the  student  is  led  to  a  correct 
understanding  of  the  interesting  principles  of  chemistry. 

In  preparation,  "ORGANIC  CHEMISTRY,"     By  the  same 

author  and  translator. 


YEO'S   PHYSIOLOGY. 

A  MANUAL  FOR  STUDENTS.     JUST  READY. 
300     CAREFULLY    PRINTED    ILLUSTRATIONS. 

FULL  GLOSSARY  AND  INDEX. 

By  Gerald  F.  Yeo,  m.d.,  f.r.c.s.,  Professor  of  Physi- 
ology in  King's  College,  London.  Small  Octavo.  750 
pages.     Over  300  carefully  printed  Illustrations. 

PRICE,  CLOTH,  $4.00;  LEATHER,  $5.00. 

"  By  his  excellent  manual,  Prof.  Yeo  has  supplied  a  want  which 
must  have  been  felt  by  every  teacher  of  physiology.  *  *  *  * 
In  conclusion,  we  heartily  congratulate  Prof.  Yeo  on  his  work, 
which  we  can  recommend  to  all  those  who  wish  to  find  within  a 
moderate  compass  a  reliable  and  pleasantly  written  exposition  of 
all  the  essential  facts  of  physiology  as  the  science  now  stands." — 
The  Dublin  "Journal  of  Med.  Science. 

"The  work  will  take  a  high  rank  among  the  smaller  text-books 
of  Physiology." — Prof.  H.  P.  Bowditch,  Harvard  Med.  School, 
Boston. 

"  The  brief  examination  I  have  given  it  was  so  favorable  that  I 
placed  it  in  the  list  of  text-books  recommended  in  the  circular  of 
the  University  Medical  College." — Prof.  Lewis  A.  Stimpson, 
M.  D.,37  East  33d  Street,  New  York. 

"  For  students'  use  it  is  one  of  the  very  best  text-books  in  Physi- 
ology."— Prof.  L.  B.  How,  Dartmouth  Med.  College,  Hanover, 
N.H. 

RINDFLEISCH. 

THE  ELEMENTS  OF  PATHOLOGY. 

TRANSLATED  BY  WM.  H.  MERCUR,  M.D. 
REVISED   AND   EDITED   BY  PROF.  JAS.  TYSON, 

Of  the  University  of  Pennsylvania. 
263  PAGES.  CLOTH.  PRICE  $2.00. 
*95*It  is  the  object  of  Prof.  Rindfleisch  to  present  in 
this  volume  of  moderate  size  the  fundamental  principles 
of  Pathology  A  large  number  of  the  general  processes 
which  underlie  disease,  a  knowledge  of  which  is  essen- 
tial to  the  practical  physician,  are  plainly  presented. 
They  include,  among  others,  inflammation,  tumor  forma- 
tion, fever,  derangements  of  nutrition,  including  atrophy, 
derangements  of  the  movement  of  the  blood,  of  blood 
formation  and  blood  purification,  hyperesthesia,  anaesthe- 
sia, convulsions,  paralysis,  etc.  The  well-known  reputa- 
tion of  the  author,  his  thorough  familiarity  with  and  his 
method  of  treating  the  subject,  make  this  most  recent  work 
peculiarly  useful  to  the  student,  as  well  as  to  the  prac- 
ticing physician  who  wishes  to  brush  up  his  pathology. 


Just  Published. 

VAN  HARLINGEN  ON  SKIN  DISEASES 

A  Handbook  of  the  Diseases  of  the  Skin,  their  Di- 
agnosis and  Treatment.  By  Arthur  Van  Harlingen,  M.D., 
Professor  of  Diseases  of  the  Skin  in  the  Philadelphia 
Polyclinic,  Consulting  Physician  to  the  Dispensary  for 
Skin  Diseases,  etc.  Illustrated  by  two  colored  litho- 
graphic plates. 

12mo.  284  PAGES.  CLOTH.  PRICE  $1.75. 
*#*This  is  a  complete  epitome  of  skin  diseases,  arranged  in  al- 
phabetical order,  giving  the  diagnosis  and  treatment  in  a  concise, 
practical  way.  Many  prescriptions  are  given  that  have  never  been 
published  in  any  text-book,  and  an  article  incorporated  on  Diet. 
The  plates  do  not  represent  one  or  two  cases,  but  are  composed  of  a 
number  of  figures,  accurately  colored,  showing  the  appearance  of 
various  lesions,  and  will  be  found  to  give  great  aid  in  diagnosing. 

BYFORD,  DISEASES  OF  WOMEN. 

NEW  REVISED  EDITION. 
The  Practice  of  Medicine  and  Surgery,  as  applied  to  the 
Diseases  of  Women.  By  W.  H.  Byford,  a.m.,  m.d., 
Professor  of  Gynaecology  in  Rush  Medical  College; 
of  Obstetrics  in  the  Woman's  Medical  College ;  Sur- 
geon to  the  Woman's  Hospital;  President  "of  the 
American  Gynaecological  Society,  etc.  Third  Edition. 
Revised  and  Enlarged;  much  of  it  Rewritten;  with 
over  1 60  Illustrations.     Octavo. 

PRICE,  CLOTH,  $5.00;  LEATHER,  $6.00. 
"  The  treatise  is  as  complete  a  one  as  the  present  state  of  our 
science  will  admit  of  being  written.  We  commend  it  to  the  diligent 
study  of  every  practitioner  and  student,  as  a  work  calculated  to  in- 
culcate sound  principles  and  lead  to  enlightened  practice  " — New 
York  Medical  Record. 

"  The  author  is  an  experienced  writer,  an  able  teacher  in  his  de- 
partment, and  has  embodied  in  the  present  work  the  results  of  a 
wide  field  of  practical  observation.  We  have  not  had  time  to  read 
its  pages  critically,  but  freely  commend  it  to  all  our  readers,  as  one 
of  the  most  valuable  practical  works  issued  from  the  American 
press." — Chicago  Medical  Examiner. 

MACKENZIE,  THE  THROAT  AND  NOSE. 

By  Morell  Mackenzie,  m.d.,  Senior  Physician  to  the 

Hospital  for  Diseases  of  the  Chest  and  Throat;  Lecturer 

on  Diseases  of  the  Throat  at  the  London  Hospital,  etc. 

Vol.  I.   Including  the  Pharynx,  Larynx,  Trachea, 

etc.     1 12  Illustrations.    Cloth,  $4.00;  Leather,  $5.00 

Vol.  II.    Diseases  of  the  CEsophagus,  Nose  and 

Naso-PHARYNX,  with  Formula  and  93  Illustrations. 

Cloth,  $3.00;  Leather,  $4.00 

The  two  volumes  at  one  time,    Cloth,  $6.00 ;  Leather,  $7.50 


OCT  19*0 


COLUMBIA   UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C28  (449)  M50 

RD731 


R25 
1885 


Reeves 

Bodily  deformities  and  their 
treatment 

- 

KD73( 


£2S 
188S 


